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. 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: 365858 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 365858 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224 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)