Health inspection·March 23, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's diet for 2 (Resident #53 and Resident #31) of 3 residents sampled for nutrition and 1 (Resident #1) of 1 residents reviewed for restraints. Residents Affected - Few Findings include: 1. During an observation on 3/20/2023 at 12:35 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, ground meat, mashed potatoes, green bean salad, juice, and crumb cake. During an observation on 3/22/2023 at 12:40 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, finely chopped chicken, noodles, green beans, apple sauce, and juice. Review of the admission record documented that Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, dysphagia following nontraumatic intracerebral hemorrhage, aphasia following cerebral infraction, and gastro-esophageal reflux disease with esophagitis without bleeding. Review of the physician order for Resident #53 dated 11/20/2022 read, Regular diet mechanical soft texture, thin/regular consistency, Diet - Mechanical soft, thin liquids. Fortified pudding with lunch and dinner for weight loss Review of Resident #53's MDS Quarterly assessment dated [DATE] read, Section K Swallowing/Nutritional Status, K0510 Nutrition approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids), 2. While a resident: 0. Not checked (No) During an interview on 3/22/2023 at 1:19 PM, the MDS Coordinator stated, [Resident #53's name] is on a mechanical soft diet. I probably saw the regular and did not go any further. 2. During an observation on 3/20/2023 at 12:39 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, ground meat, mashed potatoes, green beans, desert and juice. During an observation on 3/22/2023 at 12:43 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, finely cut chicken, noodles, apple sauce, green (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 105808 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)