Health inspection·August 21, 2023

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) Identification Screens were accurate and timely upon admission. This affected one resident (Resident #35) of three residents reviewed for PASARR. The facility census was 39. Residents Affected - Few Findings included: 1. Review of Resident #35's medical record revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (entered 06/07/23), and major depressive disorder (entered 06/07/23). Review of Resident #35's admission Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired. Resident #35 had no behaviors exhibited. Resident #35 required limited assist of one for bed mobility, transfers, independent with eating, and extensive assist for toilet use. Record review of the admission Medicare five-day Minimum Data Set, dated [DATE] for Resident #35 revealed Resident #35 was moderately cognitively impaired. Record review of Resident #35's physician orders for August 2023 revealed Resident #35 received escitalopram oxalate oral tablet 10 milligrams (mg) one tablet by mouth at bedtime for depression and aripiprazole oral tablet, 10 mg one tablet by mouth at bedtime for bipolar. Record review revealed there was no PASARR available in Resident #35's medical records. Interview on 08/15/23 9:24 A.M. with Administrator revealed the PASARR for Resident #35 was not completed on admission. Administrator revealed the PASARR was completed the previous evening after the surveyor requested it. Administrator revealed Social Service Designee (SSD) was to complete the PASARR on admission. Interview on 08/15/23 at 9:29 A.M. with SSD #122 revealed she was probably out of the building when Resident #35's PASARR was to be completed. SSD #122 confirmed Resident #35 did not have a PASARR completed until after the surveyor requested one on 08/14/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 2 of 7 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 08/21/2023 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to re-assess nutritional status and implement interventions to prevent further significant weight loss. This affected one resident (Resident #29) of three residents reviewed for nutrition. The facility census was 39. Residents Affected - Few Findings include: Record review for Resident #29 revealed an admission date of 06/13/23. Resident #29 had a hospital readmission on [DATE] and returned to the facility on [DATE]. An additional hospital readmission occurred on 07/17/23 and the resident returned to the facility on [DATE]. Diagnosis included enterocolitis due to clostridium difficile (c-diff), unspecified protein calorie malnutrition, cerebral infarction (stroke), dysphagia (difficulty or discomfort when swallowing), need for assistance with personal care and muscle weakness. Record review of the physician progress note dated 06/16/23 completed by Primary Care Physician #165 revealed Resident #29 had severe malnutrition. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was rarely or never understood. Resident #29 required extensive assistance of two persons for bed mobility, total dependence of two persons with transfers, and supervision with eating. Lastly, the resident had a weight loss of 5% or more in the last month or 10% or more in six months. Record review of the care plan dated 07/09/23 revealed Resident #29 was at risk for altered nutritional status related to diagnosis of protein-calorie malnutrition, recent lack of appetite; abnormal labs. Interventions included to administer medication and/or vitamin/mineral supplements per physician order. Monitor meal percentage intake for changes in eating habits. Periodically obtain resident's weight, evaluate, and report to Registered Dietitian (RD) and physician of significant weight changes. Record review of the physician orders revealed Resident #29 received a no added salt, regular texture, thin consistency diet dated 07/24/23. Further review revealed no nutritional supplements were ordered. Review of Resident #29's weight history revealed four weights recorded in Resident #29's medical record: 06/13/23 145 pounds (lbs) per hoyer (mechanical lift) 07/03/23 124.2 lbs per mechanical lift 08/05/23 102.4 lbs 08/08/23 102 lbs Record review revealed only one Dietary Evaluation note in Resident #29's medical record. The note was dated 07/25/23 at 8:44 A.M. and completed by Dietician #110. The Dietary Evaluation note indicated a Comprehensive Nutritional Evaluation was completed. Documentation included Resident #29 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 3 of 7 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 08/21/2023 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few presented as a significant, unplanned and undesirable weight loss related to recent hospitalization. The resident received a therapeutic no added salt (NAS) diet related to cardiac status. The Plan of Care was updated 07/24/23 with a no added salt diet, regular texture, thin consistency (diet). Review of the physician progress note dated 08/10/23 completed by Primary Care Physician #165 revealed Resident #29 had poor po (by mouth) intake, on supplements (however there were no physician orders or documentation to support the use of nutritional supplements). Review of Resident #29's meal intake records for August 2023 revealed intake for each meal, breakfast, lunch, and dinner varied from 25% to 100% consumption. Interview on 08/17/23 at 3:46 P.M. with Dietician #110 revealed she had completed an admission note for Resident #29 on 06/19/23 and made no recommendations at that time. Since then, there had been one Dietary Evaluation note in Resident #29's medical record. Dietician #110 revealed Resident #29 returned from the hospital on [DATE] and the RD's next visit was on 07/25/23. Dietician #110 revealed there was no readmission weight completed for Resident #29 because the hoyer scale was broken. Dietitian #110 confirmed the documented admission weight on 06/13/23 of 145 lbs. and the weight on 07/03/23 of 124.2 lbs was not addressed in the medical record and no interventions were implemented for Resident #29's significant, unplanned weight loss during that time. Dietician #110 verified the weight obtained on 08/08/23 confirmed a weight of 102 lbs, an additional 22 lb weight loss from 07/03/23. Dietician #110 confirmed no interventions had been implemented for the resident's significant, unplanned weight loss as of 08/17/23 at 3:46 P.M. however, Dietitian #110 verified nutritional interventions should have been implemented to prevent the resident's significant weight loss. Dietician #110 verified she had no recollection of the facility notifying her of Resident #29's continued significant weight loss. Interview on 08/21/23 at 8:20 A.M. with the Administrator revealed the dietitian visited the facility once a week but the staff were able to notify her at any time for concerns with weight loss. The Administrator confirmed the record demonstrated a 43 pound weight loss with no evidence of re-evaluation related to the resident's weight loss or implementation of interventions until brought forward by the surveyor. The Administrator verified the facility should have identified the resident's significant weight loss. Record review of the facility policy titled, Weight Assessment and Intervention revised September 2008 revealed any weight change of five % or more since the last weight assessment shall be retaken for confirmation. If the weight is verified, nursing will notify the Dietician. The Dietician will review the weight to follow individual weight trends. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 4 of 7 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 08/21/2023 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)

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 kitchen stove/oven in a safe operating manner. This had the potential to affect all 38 residents receiving food from the kitchen. The facility identified one resident (Resident #139) who received enteral nutrition. The census was 39. Residents Affected - Many Findings include: Observation of the kitchen on 08/14/23 at 10:14 A.M. revealed the facility's primary stove/oven was a six burner flat top with all but one temperature control knob for the stove's top burners missing and one of the oven temperature control knobs was missing. There was a rust-like substance on the oven doors and sides of the stove/oven. Interview on 08/14/23 at 10:15 A.M. with Kitchen Manager #108 confirmed the stove /oven control knobs were missing because the oven had malfunctioned and melted most of the oven control knobs off the stove. Kitchen Manager #108 produced one of the stove control handles that was melted on the bottom half. The Kitchen Manager stated the oven had been malfunctioning so the temperature in the oven would randomly shoot up to 500 degrees Fahrenheit, burning the food and causing the kitchen staff to have to improvise quickly to feed the residents. He stated the kitchen staff had tried to maintain the ovens temperature by testing the temperature every 10 to 15 minutes and adjusting the temperature to make sure it wasn't too high or low, but was inexact and resulted in burned food. The Kitchen Manager stated he made sure the food was cooked to safe temperatures by taking temperatures with a digital thermometer after cooking; but he had to throw the burned foods away. The Kitchen Manager #108 stated the facility had priced some new stoves but there were no specific purchase dates from the facility owners and he was told the facility may purchase a new stove in the next month or two. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 5 of 7 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 08/21/2023 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide a clean home like environment for 27 residents (Resident #1, #2, #3, #4, #8, #9, #10, #11, #12, #14, #16, #17, #18, #19, #20, #22, #24, #25, #27, #28, #29, #30, #31, #33, #34, #35, and #140) of 39 residents who participated in meals and/or activities outside of their rooms. The facility census was 39. Findings include: Observation on 08/14/23 from 9:30 A.M. through 11:30 A.M. revealed there were four halls where residents resided and traveled on throughout the facility. The nursing station was located in the center leading to each hall. All halls were carpeted including surrounding the nursing station. The carpeting in all halls including surrounding the nurses station was embedded with black dirt, grime, food, and red fluid spills. The carpeting was soiled from the beginning of each carpeted area through the end. Many areas on each hall had large black areas that were so embedded with dirt or other substances, that the fibers of the carpet were no longer visible. Interview on 08/14/23 at 10:01 A.M. with Resident #30 revealed he was upset regarding the condition of the carpet in the halls outside his room which were so terribly dirty. Observation and interview on 08/14/23 at 11:57 A.M. with the Administrator and Housekeeping Manager #120, of the four residential halls and nursing station, confirmed the carpet was embedded with black dirt, grime, food, and red fluid spills from the beginning of each carpeted area through the end. The Administrator and Housekeeping Manager #120 confirmed many areas on each hall had large black areas that were so embedded with dirt or other substances, that the fibers of the carpet were no longer visible. Housekeeping Manager #120 shared he asked about cleaning the carpet for the previous six months. Housekeeping Manager #120 said he told the Administrator what he needed to clean it, and the Administrator said she would talk to corporate. Housekeeping Manager #120 also shared that over the previous four months, he submitted quotes for new carpet scrubbers and even suggested a company coming in to clean it but he received no response. The Administrator was present during the interview with Housekeeping Manager #120 and revealed she had been asking corporate for the past six to eight weeks for a professional floor cleaning company to come into the facility and to purchase a new carpet scrubber but she has not heard nothing back yet. An observation of the laundry room on 08/16/23 at 12:30 P.M. revealed the floor tiles were dull, scuffed and had a thick buildup of dirt and grime in the two laundry rooms. Some of the floor tiles were missing and chipped. A large square section of tiles were missing in front of the dryers with a black substance covering the subfloor. An interview with Laundry Aide #100 on 08/16/23 at 12:33 P.M. stated the floor needed replaced and the floor had not been stripped or thoroughly cleaned in a very long time. An interview with Director of Nursing (DON) on 08/17/23 at 12:30 P.M. verified the above observation and verified the floor needed cleaned and waxed. Record review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 6 of 7 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 08/21/2023 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)

F 0921 regular basis, when spills occur, and when these surfaces are visibly soiled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 7 of 7