Ball Pavilion, The
Ball Pavilion, The in ERIE, PA — inspection on March 27, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
bed-hold policies.
facility failed to make certain that the necessary resident information was communicated to the
(Residents R4, R5, and R62).Findings include:Review of facility policy entitled Transfer to Hospital/Emergency dated 2/19/26, indicated Transfer of resident with the necessary paperwork and notifications once decision is made to transport; Nurse is to inform Emergency Department of transfer and will make copies of Face Sheet, Living Will (if resident has one), out of facility DNR, print out resident transfer sheet, vaccine records, and any other resident clinical records deemed necessary to be sent.Resident R4's clinical record revealed an admission date of 12/9/18, with diagnos2s that included Cerebral Infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and High Blood Pressure.Resident R4's progress notes revealed notes dated 12/6/25, indicating a transfer to the hospital.
The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.Resident R5's clinical record revealed an admission date of 7/8/24, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed), and muscle weakness.Resident R5's progress notes revealed notes dated 1/29/26, indicating a transfer to the hospital.
The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.
Resident R62's clinical record revealed an admission date of 2/18/26, with diagnoses that included Acute Respiratory Failure, Heart failure, and Dementia.Resident R4's progress notes revealed notes dated 3/6/26, indicating a transfer to assisted living.
The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.During an interview on 3/27/26, at 10:00 a.m. the Director of Nursing confirmed that Residents R4, R5, and R62's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider.28 Pa.
Code 201.18(e)(1) Management28 Pa.
Code 201.29(c.3) (2) Resident rights
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
Review of Resident R5's comprehensive care plan on 3/25/26, revealed that of the 31 care plans present, 28 had an outstanding target date (an identified date a care plan should be reviewed/revised) of 12/31/25, and two had an outstanding target date of 3/4/26.
The care plans included the problem categories of: anticoagulant therapy, diuretic therapy, congestive heart failure, risk for dehydration, risk for infection, risk for malnutrition, pressure ulcer, range of motion, antidepressant medication, enhanced barrier precautions (EBP), risk for urinary tract infection, cognition, urinary tract infection, pain, treatment, decreased cardiac output, personalized care, wound management, depression, pain control, EBP related to ESBL (type of bacteria infection), impaired physical mobility, coping, sensory perception, self-care, risk for bleeding, altered fluid balance, skin integrity, cardiac function, and fluid restriction.
Resident R55's clinical record revealed an admission date of 10/30/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), kidney disease (the gradual loss of kidney function), and high blood pressure.
Review of Resident R55's comprehensive care plan on 3/25/26, revealed that of the nine care plans present, six had an outstanding target date of 11/19/25.
The care plans included the problem categories of: personalized care, risk for urinary tract infection, psychosocial wellbeing, skin tear, discharge planning, and pain.
During an interview on 3/25/26, at 2:15 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R5 and Resident R55's care plans were not reviewed and/or revised as required. 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
Observation on 3/25/26, at 9:10 a.m. revealed that Licensed Practical Nurse (LPN) E3 prepared and delivered medications to Resident R63, observed the resident self-administer his/her nasal spray and proceeded to exit the room and leave the resident's oral medications sitting on the tray table.
During an interview at that time, LPN Employee E3 stated that Resident R63 was alert and oriented times four and so it is okay to leave his/her medications for them to take.
During an interview on 3/25/26, at 10:05 a.m. the Director of Nursing confirmed that medications should not be left in resident rooms and that staff should observe residents take their medications.
Resident R1's clinical record revealed an admission date of 2/27/26, with diagnoses that included bacterial pneumonia (infection of your lungs caused by certain bacteria), spinal stenosis, high blood pressure, and vertigo (sensation of spinning and feeling off balance).
Resident R1's admission assessment revealed that his/her admission assessment dated [DATE], was completed by an LPN.
Resident R1's departmental admission progress note dated 2/27/26, indicated that the admission assessment was completed by an LPN.
During an interview on 3/26/26, at 11:15 a.m.
Registered Nurse Employee E5 and the Infection Preventionist confirmed that Resident R1's admission assessment and following baseline care plan was completed by an LPN.
During an interview on 3/26/26, at 11:38 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R1's admission assessment and baseline care plan was completed by an LPN. 28 Pa.
Code 211.10(d) Resident care policies28 Pa.
Code 211.12(d)(1)(2)(5) Nursing services
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
Observation on 3/24/26, at 1:00 p.m. revealed Resident R1 sitting in his/her room with the supplemental oxygen tubing from the concentrator in his/her nose and the oxygen tubing cannula for his/her portable oxygen canister was hanging over the top of the canister that was attached to the back of the wheelchair.
Interview with LPN Employee E2 at that time, confirmed that the tubing for the portable canister should not be hanging over the top of the canister on the back of the wheelchair.
Observation on 3/25/26, at 11:10 a.m. revealed Resident R1 sitting in his/her wheelchair with his/her feet on top of the bed.
The concentrator tubing was in his/her nose and the tubing from the portable oxygen canister was hanging over the top of the canister that was attached to the back of the wheelchair.
Observation on 3/25/26, at 11:20 a.m. revealed Resident R1's tubing from concentrator was lying on the top of his/her bed and Resident R1 was no longer in the room.
During an interview at that time, the Infection Control nurse confirmed that the tubing should be hanging on the hook on the wall when not in use. 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
Based on observations, review of facility policies, and staff interviews, it was determined that the
Tuberculosis) in one of three medication room refrigerators (Unit B), and a multi-dose vial of insulin in one of four medication carts (Unit A-1).Findings include: Review of a facility policy entitled, Medication Storage dated 2/19/26, indicated that outdated medications are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy.
Nighttime nurse will complete medication cart check sheet daily after checking med cart and remove all expired medications.
Observation on 3/24/26, at 3:55 p.m. in the Unit B medication room refrigerator revealed a multi-dose vial of Tubersol with an expiration date of 3/22/26.
During an interview at that time Licensed Practical Nurse (LPN) Employee E1 confirmed that the vial of Tubersol was expired and should have been discarded.
Observation on 3/24/26, at 4:30 p.m. of Unit A-1 medication cart revealed a multi-dose vial of Humalog (fast-acting insulin) with an expiration date of 3/18/26.
During an interview at that time, LPN Employee E4 confirmed that the Humalog insulin was expired and should have been discarded. 28 Pa.
Code 201.18(b)(1) Management 28 Pa.
Code 211.9(a)(1) Pharmacy services 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
201.18(e)(2.1) Management
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511
Review of a departmental progress note dated 2/8/2026, revealed the Registered Dietitian recommended nutritional feeding at 80 cc/hour running 6 pm - 6 am, 12 hours via pump and to run to complete 1000 cc bag.
Water flush 140cc q 4 hours.
Feeding provides 1500 calories, 69 gm protein and 764 cc free water, plus 744 cc from water flush, for a total of 1573 cc water.
Estimated needs = 1200-1500 calories, 55-65 gm protein and 1200-1500 cc fluids.
Feeding is meeting 100% of estimated needs for calories, protein, and fluid.
Resident R49's clinical record lacked evidence that the nutritional needs outlined by the Registered Dietitian were being met and lacked evidence that staff were recording the amount of nutritional feeding and water provided.
During an interview on 3/26/26, at 3:12 p.m. the Director of Nursing confirmed Resident R49's clinical record contained incomplete and inaccurate documentation regarding tube feeding amounts and flushes. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services28 Pa.
Code 211.5(f)(viii) Medical records28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1)(3) Management
During an interview on 3/25/26, at 11:20 a.m. the Infection Preventionist confirmed that staff should use a towel to turn off the spigot, and wear gowns during medication administration through an IV or g-tube. 28 Pa.
Code 211.10(c)(d) Resident care policies28 Pa.
Code 211.12(d)(1)(5) Nursing services
395401 03/27/2026
Ball Pavilion, The 5416 East Lake Road Erie, PA 16511