Health inspection·October 14, 2021

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation and facility record review, the facility failed to maintain a clean and safe environment in resident care areas with stained carpet and unstable dining room tables. This had the ability to affect all residents residing in the facility. Facility census was 31. Findings Include: Observation of the resident hallways revealed the carpeting in the entire area had numerous carpet stains in the areas where the residents live. This was observed throughout the survey process from 10/12/21 through 10/14/21. Interview with the Director of Nursing (DON) on 10/13/21 at 2:50 P.M. revealed the facility had the carpets steam cleaned approximately six weeks earlier and Housekeeping would spot clean when necessary. Interview with the Administrator on 10/14/21 at 11:33 A.M. revealed on 07/22/21 invoice #6200 revealed a local carpet cleaning company came to the facility on [DATE] and 07/22/21 to deep clean the facility's carpeting. The carpet was pre-sprayed, then steam cleaned and deodorized throughout the entire building. The Administrator said Housekeeping then spot cleans with a machine if something spills on the floor but they were never able to get the stains out of the carpet. Observation of the dining room throughout the survey process on 10/12/21 through 10/12/21 revealed numerous tables had cardboard pieces or paper folded up and placed under the table feet because the tables were very wobbly. Interview with the DON on 10/13/21 at 2:50 P.M. revealed there were currently no plans to fix the wobbly tables because the residents are eating in their rooms. Interview with the Administrator on 10/14/21 at 9:23 A.M. revealed nothing had been done about the dining room tables but she was planning on entering a large work order to have all the tables looked at. The Administrator confirmed that the tables are potential dangerous due to their instability. This deficiency substantiates Complaint Number OH00114597. Page 1 of 3 365858 365858 10/14/2021 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #35 received the appropriate discharge notices. This finding affected one (Resident #35) of one resident reviewed for hospitalization. The facility census was 31. Findings include: Review of Resident #35's medical record revealed the resident was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including anxiety disorder, heart failure and atherosclerotic heart disease. Review of Resident #35's medical record did not reveal evidence the resident or the resident's representative was notified in writing the reason for the discharge in an easily understood language. The medical record also did not reveal evidence the ombudsman was notified of the resident's discharge to the hospital. Interview on 10/13/21 at 1:31 P.M. with Business Office Manager (BOM) #802 confirmed Resident #35 and/or the resident's representative were not notified of the reason for the discharge in an easily understood language. BOM #802 also confirmed the ombudsman was not notified of the resident's discharge in a timely manner. 365858 Page 2 of 3 365858 10/14/2021 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain the ice machine in a clean and sanitary manner. This finding had the potential to affect thirty of thirty-one residents (except Resident #18) who receive fluids in the facility. The facility census was 31. Residents Affected - Some Findings include: Observation on 10/12/21 at 12:34 P.M. revealed that when the ice ejector inside the ice machine was wiped off by Kitchen Manager #801, the paper towel had black debris on the towel. Interview on 10/12/21 at 12:40 P.M. with Kitchen Manager #801 confirmed the ice machine had not cleaned since 03/2021 and it was not maintained in a sanitary manner. 365858 Page 3 of 3