Pavilion At Brmc, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for four of 14 residents reviewed (Residents R1, R2, R6, and R30). Findings include: Facility policy entitled Physician Visit Scheduled dated 11/28/25, revealed All attending physicians will visit the residents of the Pavilion at BRMC once monthly and document a progress note relative to the MD visit. Resident R1 was admitted [DATE], with diagnoses that included Dementia (loss of cognitive functioning affecting a person's memory and behaviors), Wernicke Encephalopathy (Neurological Disorder caused by severe deficiency of thiamine leading to brain dysfunction. Commonly seen in people with chronic alcohol abuse, malnutrition and conditions that impair nutrient absorption), and High Blood Pressure. Resident R1's clinical record revealed physician progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary operations and standards for food safety in one of two resident unit freezers reviewed (Third Floor).Findings include: Observations on 4/21/26, at 11:26 a.m. of the Third Floor freezer revealed two ice packs that are used for treatments on residents stored next to frozen microwave meals. During an interview on 4/21/26, at 11:26 a.m. Certified Nursing Assistant Employee E1 confirmed that the ice packs used as treatments for residents were in the freezer with food. He/she confirmed that ice packs used as treatments should not be stored in the same unit with food. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on a review of facility policy, facility grievances, and resident and staff interviews, it was determined that the facility failed to provide acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance for two of 19 residents reviewed (Residents R9 and R11). Findings include: Review of the facility policy entitled, Pavilion Complaint/Grievance Policy, dated 12/28/23, revealed that the Pavilion grievance official will oversee the Pavilion grievance process, receive and track grievances through their conclusion, will lead any necessary investigation by the facility, will maintain confidentiality of all information associated with grievances, will be responsible in issuing written grievance decision to the resident/resident representative and will coordinate with state and federal agencies as necessary in light of specific allegations. The grievance official of the Pavilion will also take immediate action to prevent potential violation of any resident right while the alleged violation is being investigated. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity by placing a wander guard bracelet (a device with a small box on a plastic bracelet placed on an at risk wandering person to alert the staff if that person attempts to exit the facility without staff supervision) on one of two residents reviewed for wander guard usage (Resident R24). Findings include: Review of a facility policy entitled General Safety Practices at The Pavilion dated 12/28/2023, revealed All residents at risk for elopement will be placed on the second floor and a wander guard bracelet will be initiated. Review of Resident R24's clinical record revealed an admission date of 4/15/16, with diagnoses that included hypertension (high blood pressure), heart failure (a condition where the heart cannot supply the body with enough blood), presence of artificial knee joint, and edema (swelling to an area of body due to holding excessive fluid). Review of residents that reside on the second floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed correctly to indicate the code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 19 residents reviewed (Resident R39). Findings include: Review of a facility policy Advance Directives-Health Care Proxy, MOLST/POLST, Living Will dated [DATE], revealed All adult individuals in New York State and in Pennsylvania have the right to self-determination in Health Care and the right to express their preferences regarding health care treatment, including decisions to continue or refuse routine or major medical treatment, as well as life-sustaining treatment without which the individual is expected to die. Advance directives such as health care proxies (HCP), living wills and consents to Do Not Resuscitate (DNR) orders allow an adult to express his/her healthcare treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan regarding the use of side rails for one of 17 residents reviewed (Resident R32). Findings include: Review of a facility policy entitled Resident Care Plan dated 12/28/23, indicated that the facility will develop a comprehensive care plan of care to reflect the needs of the resident, be individualized and resident driven, and utilize nursing assessments, evaluations, etc. Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalized muscle weakness, heart disease, arthritis, and limitations of activities due to disability. Current physician's orders for January 2024, indicated that Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record lacked evidence of a care plan to address his/her side rail use. Review of Resident R32's clinical record documentation the daily use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer supplemental oxygen as ordered and promote cleanliness regarding respiratory care equipment according to physician orders for one of 19 residents reviewed (Resident R17). Findings include: Review of a facility policy entitled Care of Oxygen Tubing/Nebulizer Tubing and Filters dated 12/28/23, indicated that oxygen concentrator filters will be cleaned monthly. Review of a facility policy entitled Medication Administration dated, 12/28/23, revealed that medications shall be administered in accordance with the orders of the prescribing Healthcare Practitioner, and oxygen administration must have a physician order, the order must be written on the Medication Administration Record (MAR) and the nurse is to monitor oxygen flow rate every shift. Resident R17's clinical record revealed an admission date of 1/25/14, with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records and facility policy, and staff interviews it was determined that the facility failed thoroughly review and assess the use of bed rails prior to their use and review the risk versus benefits of using bed rails with the resident's representative and obtain informed consent for the installation and use of bed rails prior to the installation for two of 19 residents reviewed (Residents R32 and R67). Findings include: Review of a facility policy entitled Side Rails and Use of ½ Side Rails dated 12/28/23, indicated that half side rails may be utilized to assist a resident with bed mobility and transfers or to assist the resident with bed controls but only after an individual Side Rail assessment is completed on admission, quarterly, annually, and as needed. Resident R32's clinical record revealed an admission date of 10/19/16, with diagnoses that included dementia, generalize muscle weakness, heart disease, arthritis, and limitations of activities due to disability.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 19 residents (Resident R32). Findings include: Review of a facility policy entitled Standard Precautions dated 12/28/23, revealed that staff are expected to change their gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms, and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Observation of wound care on 1/03/24, at 3:12 p.m. revealed that Registered Nurse (RN) Employee E3 performed hand hygiene and donned (put on) clean gloves; removed the soiled dressing containing a moderate amount of exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation); picked up the multi-use bottle of wound cleanser; applied wound cleanser solution to two, four inch by four inch cotton gauzes;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.