Health inspection·March 21, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for three of 24 residents reviewed (Residents R35, R51, and R52). Residents Affected - Some Findings include: Resident 35's clinical record revealed an admission date of 10/01/24, with diagnoses including dementia, stroke with right-sided weakness, Schizophrenia (a serious mental health condition that affects how people think, feel and behave, and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), and intellectual disabilities. Review of R35's Quarterly MDS dated [DATE], under Section M0300, Skin Conditions revealed it was coded as having a Stage Three (full thickness tissue loss). Resident R35's clinical record revealed assessment documentation provided by the contracted wound care specialist as follows: -11/11/24, initial examination of moisture associated skin damage (MASD- erosion or inflammation of the skin caused by long-term exposure to moisture) partial thickness wound to the gluteal cleft. -11/25/24, follow-up assessment MASD partial thickness wound to the gluteal cleft. Resident R51's clinical record revealed an admission date of 7/08/24, with diagnoses including sepsis (the body's immune system has an extreme response to an infection, causing organ dysfunction), Stage Four pressure ulcer of the right buttock (full-thickness tissue loss with exposed bone, tendons, or muscle), and quadriplegia (paralysis that affects all a person's limbs). Review of Resident R51's Quarterly MDS dated [DATE], under Section M0300, Skin Conditions revealed it was coded as a Stage Four, not present on admission. Resident R51's clinical record revealed assessment documentation provided by the contracted wound care specialist dated 12/09/24, and indicated that his/her Stage Four wound was not acquired at the facility. Resident R52's clinical record revealed an admission date of 6/20/18, with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure. (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 6 Event ID: 395401 Printed: 05/15/2026 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 395401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ball Pavilion, The 5416 East Lake Road Erie, PA 16511 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)