Health inspection·April 18, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, plumbing company interview and, review of plumbing invoices and quotes, this facility failed to timely fix/replace a non-working hot water heater that was used to provided hot water to the facility's laundry room. This had the potential to affect all residents residing in the facility at this time. The facility census was 81. Findings included: Review of the provided Quote from a local Plumbing, Heating and Cooling Company #1 dated 02/28/23 revealed the facility was provided a quote for the cost of $18,125.25 to replace the water heater in the facility ' s laundry room and for the labor to complete this work. Summary of work included: 1. Backordered Expected May 26, 2023, through August 24, 2023. 2. Remove the existing water heater. 3. Install new AO [NAME] BRT - 365, 85 Gallon, 365,000 Gas Water Heater. 4. New heater to be ASME Construction. 5. Company providing the quote to supply State Permit and State Inspection. 6. Clean job site and leave water heater in good working order. Interview on 04/14/23 at 10:30 A.M. with the Administrator revealed the hot water tank located in the laundry room has not been functioning for a little over a month now. The Administrator claimed the facility had been in contact with plumbing companies obtaining quotes to have the hot water tank replaced and the work completed but each company they contact claim the hot water tank that is needed is on backorder and will take a few months to get in. The Administrator did not confirm during this time if a company was officially contracted to order the needed hot water tank and complete the work. The Administrator denied receiving any complaints or concerns from any of the residents or their family members regarding the facility's hot water temperatures. Interview on 04/14/23 at 10:12 A.M. with Laundry Aide #10 confirmed the hot water tank that provided hot water to the facility's laundry room was not working properly and had not been working for a few months now, but she could not recall how long it had been exactly. Interview on 04/14/23 from 11:50 A.M. through 12:30 P.M. with Maintenance Director #5 confirmed the hot water tank located in the facility's laundry room was not currently working and has not been working for almost two months now. Review of the provided Quote from Plumbing, Heating and Cooling Company #1 dated 04/18/23 revealed a estimate for labor and material to install a new water heater in the laundry room with an estimated cost of $13,299.00. This estimated quote was noted to be approved on 04/18/23 by the facility for replace hot water heater to be ordered for replacement and for the plumbing company to complete the (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 2 Event ID: 365446 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 365446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Piketon 7143 Route 23 South Piketon, OH 45661 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)