Health inspection·April 12, 2023

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 and interview, the facility failed to ensure an allegation of verbal abuse was reported timely to the State agency. This finding affected one (Resident #4) of three residents reviewed for potential abuse. Findings include: Review of Resident #4's medical record revealed she was admitted on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia, unsteadiness on her feet and unspecified lack of coordination. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited moderate cognitive impairment. Review of Resident #4's undated Witness Statement form authored by State Tested Nursing Assistant (STNA) #805 indicated she was on her way down the hall when she heard Registered Nurse (RN) #803 told the resident your going to lay there and die. The nurse then told the STNA while standing in Resident #4's doorway, she was white trash and she hated white trash. She hated all trash but she hated white trash and she was a (explicit). She had a [AGE] year old child who wanted nothing to do with her because she was a junky who was doing heroin. Review of the facility Self Reported Incident (SRI) history revealed no evidence the facility reported what STNA #805 had witnesses as an allegation of verbal abuse to the State Agency. Interview on 04/10/23 at 6:53 A.M. with the Administrator indicated an STNA reported an allegation of verbal abuse and both staff were in the resident's doorway during the incident. She indicated Resident #4 did not report any concerns when interviewed. She confirmed a SRI on abuse was not reported to the State. Review of the Abuse, Neglect, Exploitation and Misappropriation Prevention policy revised 04/21 indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Page 1 of 2 365858 365858 04/12/2023 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one resident (Residents #39) of three residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #39's medical record revealed she was admitted on [DATE] with diagnoses including infection and inflammatory reaction due to an internal left hip prosthesis, presence of left artificial hip joint and Alzheimer's disease with late onset. Review of Resident #39's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment. Review of Resident #39's Wound Certified Nurse Practitioner (CNP) Note dated 02/08/23 indicated a new (initial encounter) diabetic ulcer to the left heel measured 0.6 cm (centimeters) length by 1.5 cm width by 0.2 cm depth with moderate sero-sanguineous drainage with no odors and no signs or symptoms of an infection. A new physician order for the left heel to be cleaned with normal saline, patted dry, triad paste applied and covered with a bordered foam dressing to be changed three times a week and as needed. Review of Resident #39's medication administration records (MARS) and treatment administration records (TARS) from 02/08/23 to 02/21/23 did not reveal wound treatments were completed to the left diabetic heel wound. Interview on 04/11/23 at 9:47 A.M. with the Administrator, RN Regional Director of Clinical Operations and Interim Director of Nursing (DON) #832 and [NAME] President of Clinical Operations #999 confirmed Resident #38's medical record did not have evidence the left heel diabetic wound care was completed from 02/08/23 to 02/21/23. Review of the Prevention of Pressure Injuries policy revised 04/20 indicated to evaluate, report and document potential changes in the skin. This deficiency represents non-compliance investigated under Complaint Number OH00141895. 365858 Page 2 of 2