Health inspection·April 17, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, and interviews, the facility failed to appropriately report an allegation of resident to resident abuse to the proper agencies. This affected one resident (Resident #73) out of three reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #73 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: diabetes mellitis type II, post-traumatic stress disorder, muscle weakness, Bipolar disorder, psychoactive substance abuse, altered mental status, dysphagia, lack of coordination, low back pain, alcohol abuse, nicotine dependence, hypertension, and gastro-esophageal reflux disease. This resident is alert and oriented and has minimal cognitive deficits according to the Minimum Data Set (MDS) assessment completed on 03/22/25. Review of nursing notes from 4/12/25 at 10:35 A.M. revealed Resident #73 reported feeling threatened by the resident located across the hall. Resident #73 stated that Resident #62 had made threatening comments towards him, including saying he doesn't like him. More seriously Resident #73 claims that Resident #62 has stated there is a hit out on him and threatened to beat him up or kill him or would have his buddies do it. Resident #73 also expressed concern that Resident #62 possesses a knife. Resident #73 states this is all over him having a girlfriend and Resident #62 not having one. Activity Director #111 immediately let the I wing nurse aware of the situation, the I wing nurse and Activity Director #111 immediately went down to Resident #62's room to ask Resident #62 if he did have a knife on his person, and the resident stated no. But the nurse had seen the knife located in his basket. Nurse immediately notified the Director of Nursing of the situation and both residents are being monitored at this time. The knife was removed and locked up in the activity directors office. This was written by Activity Director #111. Review of nursing note dated 4/12/2025 at 11:35 A.M. revealed Activity Director #111 had offered to show/ move Resident #73 to a new hallway after the incident had occurred and resident stated no he did not want to move, just hope nothing happens. This was written by Activity Director #111. Interview with Resident #73 on 04/14/25 at 02:52 P.M. stated another resident had a knife and threatened him. Resident stated he felt afraid at the time, and is still fearful. (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 7 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 04/17/2025 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)