Health inspection·April 17, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the bathroom floor and placed them in a plastic bag and took them to the utility room. STNA #112 washed his hands after placing the soiled items in the utility room. STNA #112 confirmed he placed Resident #6's soiled incontinence brief and draw sheets directly on the floor next to her bed, and he should not have done that. Interview on 04/15/24 at 7:45 A.M. revealed the Director of Nursing (DON) was made aware Resident #6's soiled incontinence brief, liner and draw sheets were placed on the floor during incontinence care and the DON confirmed the items should not have been put on the floor. The DON was made aware a soiled incontinence brief was observed on the floor in Resident #6's bathroom and there was no trash can. The DON confirmed the soiled incontinence brief should not have been left on the bathroom floor. Review of the facility policy titled Perineal Care revised 02/2018 included the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. The policy stated to discard disposable items into designated containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 2 of 17 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 04/17/2024 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 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, interview, record review the facility failed to ensure Resident #10's physician ordered diagnostic test was scheduled timely. This affected one resident (Resident #10) out of three residents reviewed for appointments. The facility census was 36. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed an admission date of 06/24/23 and diagnoses included chronic kidney disease, stage four, morbid obesity, major depressive disorder and type two diabetes mellitus with diabetic polyneuropathy. Review of Resident #10's physician orders dated 07/25/23 revealed Resident #10 would have a sleep study done on 07/27/23 at 8:30 P.M. at a sleep study location. Resident #10 needed to have a shower and be free of any lotions, oils, no caffeine or chocolate after 12:00 P.M. on 07/25/23. No OTC (over the counter) medication, no nail polish. Resident #10 could bring a pillow and wear loose, comfortable clothing. Review of Resident #10's progress notes dated 07/28/23 at 5:39 A.M. revealed Resident #10 was scheduled for a sleep study. Transportation did not pick her up. Resident #10 was aware that the facility would reschedule her appointment and transportation. Review of Resident #10's progress notes dated 07/28/23 at 10:49 A.M. revealed the local hospital was contacted to reschedule Resident #10's sleep study and was informed that Resident #10 had to be accompanied by an aide to the appointment for liability reasons. Review of Resident #10's progress notes and physician orders from 07/28/23 through 04/15/24 did not reveal evidence Resident #10's sleep study diagnostic test was rescheduled. Review of Resident #10's hospital admission paperwork and After Visit Summary from 09/24/23 through 09/29/24 revealed Resident #10 was hospitalized and the paperwork did not reveal evidence the hospital was aware a sleep study needed to be completed while Resident #10 was admitted to the hospital. Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 had moderate cognitive impairment. Resident #10 was always incontinent of urine and bowel. Resident #10 used a wheelchair, and required partial to moderate assistance to roll right and left. Review of Resident #10's care plan with a target date of 06/18/24 included Resident #10 had impaired respiratory status related to anxiety, chronic obstructive pulmonary disease, emphysema. Resident #10 would be free of complications related to altered respiratory status through the next review. Interventions included for labs and diagnostic testing to be completed as ordered. Interview on 04/15/24 at 10:48 A.M. with Ombudsman #128 revealed about six or seven months ago Resident #10 was supposed to have a sleep study diagnostic test, but it was not done. Ombudsman #128 stated Resident #10 talked to the Director of Nursing (DON) about the sleep study not being done, and it still has not been done. Interview on 04/15/24 at 2:49 P.M. with the DON confirmed Resident #10's sleep study diagnostic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 3 of 17 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 04/17/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few test ordered months ago had not been completed. The DON stated the facility tried multiple times to schedule the sleep study, and it was challenging because the sleep study needed to be done at the facility because the sleep study provider told the facility Resident #10 had to be accompanied by an aide for the appointment, and the facility had to send a mechanical lift with Resident #10. The DON stated they finally found a provider who could do the sleep study at the facility, and before they could schedule the sleep study appointment Resident #10 was admitted to the hospital for a few days. The DON stated the hospital said they could do the sleep study while she was admitted , but it was not done. The DON indicated readmission orders from the hospital did not have orders for a sleep study, and the facility did not realize it was not done. The DON stated Resident #10 did not tell her the sleep study was not completed. Observation on 04/16/24 at 11:36 A.M. of Resident #10 revealed she was lying in bed with the head of the bed elevated. Interview on 04/16/24 at 11:36 A.M. with Resident #10 revealed she was told by her pulmonologist about six or seven months ago she needed a sleep study diagnostic test completed, but it fell by the wayside. Resident #10 stated too many people handle the appointments and her appointment was lost in the shuffle. Resident #10 stated she was not aware the sleep study was supposed to be done while she was admitted to the hospital last year. Resident #10 indicated she told Licensed Practical Nurse (LPN) #129 and the Director of Nursing (DON) her sleep study was not done, they said they were going to make sure it was scheduled, but so much was going on, a lot of staff were quitting, the facility was trying to care for the residents and the sleep study did not get scheduled. Interview on 04/16/24 at 12:06 P.M. with LPN #129 revealed Resident #10 had an appointment with her pulmonologist last year around July and came back with an order for a sleep study. LPN #129 stated she found a provider who would come to the facility and complete Resident #10's sleep study test, but before she could get the sleep study scheduled Resident #10 was admitted to the hospital for a couple days, and she had quite a few appointments for different things like a mammogram, an appointment to discuss an arteriovenous fistula for dialysis. LPN #129 stated transportation was also an issue and Resident #10's sleep study never got scheduled, and now it had been too long and the facility needed a new order to have the sleep study completed. LPN #129 confirmed Resident #10 told her the sleep study was not completed but LPN #129 could not remember when she was told. Interview on 04/16/24 at 4:20 P.M. with Social Services Designee (SSD) #130 revealed she first was involved with Resident #10's sleep study in 09/2023. SSD #130 stated Resident #10's oxygen saturation levels were dropping at night and the sleep study needed to be scheduled. SSD #130 indicated Resident #10 wanted to be discharged home, a care conference was scheduled for 09/2023 but was postponed when Resident #10 was admitted to the hospital. Resident #10's care conference was held in 10/2023 and Resident #10 wanted to got home and have all her appointments and tests done from home. SSD #130 indicated Resident #10 did not go home because she was having problems with edema and had become agitated about all her issues. SSD #130 stated she was working on a safe discharge for Resident #10 and Resident #10 was not able to leave the facility. SSD #130 stated she did not know anything more about Resident #10's sleep study. Review of the facility policy titled Resident Rights revised 02/2021 included resident's had the right for communication with and access to people and services, both inside and outside the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 4 of 17 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 04/17/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #1 and #10 received incontinence care timely. This affected two residents (Resident's #1 and #10) out of three resident's reviewed for incontinence care. The facility census was 36. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 08/30/18 and diagnoses included dementia without behavioral, psychotic, mood disturbance and anxiety, type two diabetes mellitus with hyperglycemia, and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was frequently incontinent of urine and bowel. Resident #1 was dependent on staff for toileting hygiene. Review of Resident #1's care plan with a target date of 07/11/24 included Resident #1 had episodes of bladder and bowel incontinence related to the need for assistance with ADL's (Activity of Daily Living) and diagnoses. Resident #1 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to assist Resident #1 with toileting needs, monitor peri-area for redness, irritation, skin excoriation and breakdown, and provide peri-care after each incontinent episode and apply house barrier after incontinence care. Resident #1 had behaviors including refusal to allow incontinence care when incontinent. Interventions included to approach Resident #1 in a calm manner to avoid frustration and behavior escalation. If Resident #1 became agitated and showed signs of escalation, reapproach later. Review of Resident #1's Skin Inspection dated 04/11/24 revealed no new observed skin issues. Review of Resident #1's progress notes from 04/11/24 through 04/15/24 did not reveal notes regarding redness to Resident #1's buttocks, perineal area or groin area. Observation on 04/15/24 at 5:43 A.M. revealed State Tested Nursing Assistant's (STNA)'s #105 and #112 were preparing to provide incontinence care for Resident #1. STNA's #105 and #112 proceeded to provide Resident #1's incontinence care and when her incontinence brief was removed it was saturated with urine and she was also wearing a liner which was saturated with urine. Resident #1's reusable draw sheet which was underneath her was wet with urine. Observation of Resident #1's buttocks, labia, and the crease of both her thighs and groin area revealed chafing and redness. STNA #112 confirmed Resident #1's buttocks, labia, and the crease of both her thighs and groin area were chafed and red, and her incontinence brief, liner and draw sheet were saturated with urine. STNA #112 stated he knew Resident #1 needed changed, but he was not able to provide incontinence care because there were only two STNA's working the night shift and he was too busy to provide incontinence care until now. STNA #112 stated he thought the last time he provided Resident #1's incontinence care was around 2:30 A.M. After Resident #1's incontinence care was completed STNA #105 did not apply barrier cream, but sprinkled baby powder on her perineal area and buttocks. STNA #105 stated the baby powder helped soak up the wetness in Resident #1's perineal area. Observation of Resident #1 during the incontinence care did not reveal she refused to have her incontinence brief changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 5 of 17 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 04/17/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/15/24 at 7:45 A.M. with the Director of Nursing (DON) revealed she was informed by the surveyor Resident #1's buttocks, labia, the creases of her thighs and [NAME] area were red and chafed. The DON stated in the past Resident #1 had MASD (moisture associated skin damage), a fungal infection in her groin area, and had nystatin powder ordered to treat the fungal infection. The DON indicated she did not know Resident #1 had redness and chafing to her buttocks, groin, labia and creases of her thighs at this time. The DON stated Resident #1 refused to have her incontinence brief changed at times. Interview on 04/16/24 at 10:33 A.M. with STNA #126 revealed Resident #1 was alright to take care of, she was a little stubborn, but with a little encouragement the aides were able to change her incontinence brief. STNA #126 stated if Resident #1 refused to have her brief changed she would give her a little time, return to the room and Resident #1 would usually let her change her soiled brief. Sometimes STNA #126 brought a nurse with her and Resident #1 always allowed her brief to be changed if there were two staff changing her. STNA #126 stated Resident #1 was more likely to refuse to have her brief changed in the afternoon toward evening, and that was when two staff was helpful. Review of the facility policy titled Perineal Care revised 02/2018 included the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. 2. Review of Resident #10's medical record revealed an admission date of 06/24/23 and diagnoses included chronic kidney disease, stage four, morbid obesity, major depressive disorder and type two diabetes mellitus with diabetic polyneuropathy. Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 had moderate cognitive impairment. Resident #10 was always incontinent of urine and bowel. Resident #10 used a wheelchair, and required partial to moderate assistance to roll right and left. Review of Resident #10's care plan with a target date of 06/18/24 included Resident #10 had episodes of bladder and bowel incontinence related to her diagnoses. Resident #10 would be a reduced risk for complications from incontinence through the next review. Resident #10 would be comfortable, clean, dry, and free from skin breakdown through the next review. Interventions included to assist Resident #10 with toileting needs, to provide peri-care after each incontinent episode, apply house barrier after incontinence care. Further review of Resident #10's care plan did not reveal a care plan for providing incontinence care during the night and when she was sleeping. Observation on 04/15/24 at 6:03 A.M. of STNA #105 and Licensed Practical Nurse (LPN) #118 revealed they were preparing to provide incontinence care for Resident #10. STNA #105 stated the last time Resident #10 was provided incontinence care was on 04/14/24 at around 10:30 P.M. to 11:00 P.M. STNA #105 stated Resident #10 let them know when she wanted her incontinence brief changed. STNA #105 and LPN #118 proceeded to provide Resident #10's incontinence care and when Resident #10's brief was removed it was observed to be saturated with urine, and the reusable draw sheet underneath Resident #10 was soaked with urine and dried urine could be seen around the edges of the wet urine. Resident #10 stated she had been awake since 4:30 A.M. waiting for STNA #105 to change her, and she did not put her call light on because she knew there were only two STNA's working and she was waiting for them to get to her. Interview on 04/15/24 at 11:36 A.M. with Resident #10 revealed if she was awake it was uncomfortable for her to lay in a wet brief. Resident #10 stated when there were only two aides working like on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 6 of 17 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 04/17/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 04/15/24 it made it hard for the aides to change residents timely. Resident #10 confirmed she was awake on 04/15/24 at 4:30 A.M., was laying in a wet brief waiting to be changed and it was uncomfortable. Resident #10 stated it was not fair to the residents to only have two STNA's working because it was hard to get changed timely on those days. Resident #10 stated she was the Resident Council President and heard stories about residents being left wet and not changed timely, but she could not provide names of the residents. Review of the facility policy titled Perineal Care revised 02/2018 included the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Interview on 04/15/24 at 2:49 P.M. with the Director of Nursing (DON) revealed Resident #10 told her if she was asleep not to wake her up to change her because she is a light sleeper and would rather sleep than be changed. This deficiency represents non-compliance investigated under Complaint Number OH00152225. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 7 of 17 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 04/17/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure sufficient staffing to meet the needs of the residents. This affected Resident's #1, #6, #10, #21, #23 and had the potential to affect all the residents residing in the facility. The facility census was 36. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 04/01/21 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic nephropathy, and a personal history of urinary tract infections. Review of Resident #21's Quarterly Nutrition Evaluation dated 07/17/23 included Resident #21's diet order was low concentrated sweets, no added salt. Resident #21 was at risk for dehydration. Further review revealed to encourage fluids with and between meals for Resident #21, and might need to prompt, remind, cue and, or present fluids to Resident #21 to assure adequate fluid intake and hydration status. Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 required partial to moderate assistance to roll left and right, required supervision or touching assistance to walk ten feet, and was dependent to walk fifty feet with two turns. Review of Resident #21's care plan with a review date of 06/09/24 included Resident #21 preferred two cups of ice water at times. Resident #21's preferences would be honored. Interventions did not include an intervention for Resident #21's preference of having two cups of ice water. Observation on 04/15/24 at 1:41 P.M. of Resident #21 revealed she was lying in her bed with the head of her bed elevated. There was a styrofoam cup in front of Resident #21 on the bedside table, and there was no date written on the cup. The cup was nearly empty with no ice. Interview on 04/15/24 at 1:41 P.M. with Resident #21 revealed she did not get water today, and the nurse brought her water after she asked and Resident #21 pointed to the styrofoam cup in front of her. Resident #21 stated she wanted two cups of ice water on day shift, one cup of ice water with breakfast, then one cup of ice water between breakfast and lunch. Resident #21 indicated she did not get two cups of ice water at the times she preferred, and did not get any water at all until she asked the nurse to provide it. Resident #21 indicated she would be happy if she received two cups of ice water at breakfast and between breakfast and lunch. Resident #21 stated bedtime was horrible, I like to have water at night and I do not get it. Resident #21 indicated there were not enough State Tested Nursing Assistants (STNA)s to take care of the residents. Resident #21 stated she often did not get ice water in the morning as she preferred and requested. Interview on 04/15/24 at 1:41 P.M. with STNA #110 revealed she did not pass water to the residents in her assignment today and Resident #21 was part of her resident assignment. STNA #110 confirmed Resident #21 did not receive ice water today since she arrived for work at 6:30 A.M. STNA #110 stated she had 14 or 15 residents to take care of today, over half of them required total care, and she was behind all day. STNA #110 said she made sure the residents who needed their incontinence briefs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 8 of 17 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 04/17/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many changed had that completed first and she did not always have time to get water passed. STNA #110 stated sometimes she was just running from resident to resident trying to take care of them. Interview on 04/16/24 at 2:30 P.M. with the Administrator revealed water might not get passed in the morning, but the STNA's shift was not over yet and water would be passed before the STNA's left for the day at 6:30 P.M. The Administrator stated he was aware Resident #21 often did not have ice water given to her in the morning per her preference. Interview on 04/16/24 at 1:55 P.M. with the Director of Nursing (DON) confirmed she was aware Resident #21 often did not receive ice water and had talked to the STNA's about it, and had called to remind the aides to give ice water to Resident #21. The DON stated she was aware Resident #21 did not receive ice water today. The DON indicated the aides shift was not over yet and Resident #21 could ask the aides to give her ice water. 2. Review of Resident #23's medical record revealed an admission date of 10/26/20 and diagnoses included unspecified psychosis not due to a substance or known physiological condition, dementia with other behavioral disturbance, psychotic disorder with delusions due to known physiological condition. Review of Resident #23's Annual MDS 3.0 assessment dated [DATE] revealed Resident #23 had moderate cognitive impairment. Resident #23 used a wheelchair and required partial to moderate assistance to roll right and left and Resident #23 was not able to walk. Review of Resident #23's care plan with a target date of 06/28/24 included Resident #23 was at increased risk for altered nutritional status including Resident #21 needed alternate fluid consistency and was on a diuretic. Resident #23 would be free of signs and symptoms of dehydration. Interventions included to encourage and provide intake of fluids throughout the day, and might need to prompt, remind, cue, and or present fluids to Resident #23 to help assure adequate fluid intake and hydration status. Review of Resident #23's Comprehensive Nutritional Evaluation dated 03/19/24 included Resident #23 was on a regular diet, regular consistency. Resident #23 was at risk for dehydration, and Resident #23's estimated fluids were 2525 cc's (cubic centimeters) per day. Continued on diuretic therapy, fluids to be encouraged with and between meals. Might need to prompt, remind, cue, and, or present fluids to Resident #23 to help assure adequate fluid intake and hydration status. Observation on 04/15/24 at 1:08 P.M. of Resident #23 revealed she was lying in bed with the head of the bed elevated. A styrofoam cup, undated was sitting on a bedside table in front of Resident #23. The cup was nearly empty with no ice. Interview on 04/15/24 at 1:08 P.M. with Resident #23 revealed she did not have water passed to her by the aides today. Resident #23 stated the styrofoam cup was from last night, no aides had given her water including ice water today, and she would like to have some ice water. Interview on 04/15/24 at 1:41 P.M. with STNA #110 revealed she did not pass water to the residents in her assignment today and Resident #23 was part of her resident assignment. STNA #110 confirmed Resident #23 did not receive ice water today since she arrived for work at 6:30 A.M. STNA #110 stated she had 14 or 15 residents to take care of today, over half of them required total care, and she was behind all day. STNA #110 said she made sure the residents who needed their incontinence briefs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 9 of 17 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 04/17/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many changed had that completed first and she did not always get water passed. STNA #110 stated sometimes she was just running from resident to resident trying to take care of them. 3. Review of Resident #1's medical record revealed an admission date of 08/30/18 and diagnoses included dementia without behavioral, psychotic, mood disturbance and anxiety, type two diabetes mellitus with hyperglycemia, and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was frequently incontinent of urine and bowel. Resident #1 was dependent on staff for toileting hygiene. Review of Resident #1's care plan with a target date of 07/11/24 included Resident #1 had episodes of bladder and bowel incontinence related to the need for assistance with ADL's (Activity of Daily Living) and diagnoses. Resident #1 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to assist Resident #1 with toileting needs, monitor peri-area for redness, irritation, skin excoriation and breakdown, and provide peri-care after each incontinent episode and apply house barrier after incontinence care. Observation on 04/15/24 at 5:43 A.M. revealed State Tested Nursing Assistant's (STNA)'s #105 and #112 were preparing to provide incontinence care for Resident #1. STNA's #105 and #112 proceeded to provide Resident #1's incontinence care and when her incontinence brief was removed it was saturated with urine and she was also wearing a liner which was saturated with urine. Resident #1's reusable draw sheet which was underneath her was wet with urine. Observation of Resident #1's buttocks, labia, and the crease of both her thighs and groin area revealed chafing and redness. STNA #112 confirmed Resident #1's buttocks, labia, and the crease of both her thighs and groin area were chafed and red, and her incontinence brief, liner and draw sheet were saturated with urine. STNA #112 stated he knew Resident #1 needed changed, but he was not able to provide incontinence care because there were only two STNA's working the night shift and he was too busy to provide incontinence care until now. 4. Review of Resident #10's medical record revealed an admission date of 06/24/23 and diagnoses included chronic kidney disease, stage four, morbid obesity, major depressive disorder and type two diabetes mellitus with diabetic polyneuropathy. Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 had moderate cognitive impairment. Resident #10 was always incontinent of urine and bowel. Resident #10 used a wheelchair, and required partial to moderate assistance to roll right and left. Review of Resident #10's care plan with a target date of 06/18/24 included Resident #10 had episodes of bladder and bowel incontinence related to her diagnoses. Resident #10 would be a reduced risk for complications from incontinence through the next review. Resident #10 would be comfortable, clean, dry, and free from skin breakdown through the next review. Interventions included to assist Resident #10 with toileting needs, to provide peri-care after each incontinent episode, apply house barrier after incontinence care. Review of the facility nursing staff assignment sheets dated 04/12/24 revealed LPN #100 worked from 6:00 P.M. until 6:00 A.M. Further review revealed LPN #119 had a line drawn through her name and LPN #115's name was hand written by LPN #119's name. Further review revealed STNA #105 called off and STNA's #103 and #112 were scheduled to work night shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 10 of 17 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 04/17/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 04/15/24 at 6:03 A.M. of STNA #105 and Licensed Practical Nurse (LPN) #118 revealed they were preparing to provide incontinence care for Resident #10. STNA #105 stated the last time Resident #10 was provided incontinence care was on 04/14/24 at around 10:30 P.M. to 11:00 P.M. STNA #105 stated Resident #10 let them know when she wanted her incontinence brief changed. STNA #105 and LPN #118 proceeded to provide Resident #10's incontinence care and when Resident #10's brief was removed it was observed to be saturated with urine, and the reusable draw sheet underneath Resident #10 was soaked with urine and dried urine could be seen around the edges of the wet urine. Resident #10 stated she had been awake since 4:30 A.M. waiting for STNA #105 to change her, and she did not put her call light on because she knew there were only two STNA's working and she was waiting for them to get to her. Interview on 04/16/24 at 11:36 A.M. with Resident #10 revealed if she was awake it was uncomfortable for her to lay in a wet brief. Resident #10 stated when there were only two aides working like on 04/15/24 it made it hard for the aides to change residents timely. Resident #10 confirmed she was awake on 04/15/24 at 4:30 A.M., was laying in a wet brief waiting to be changed and it was uncomfortable. Resident #10 stated it was not fair to the residents to only have two STNA's working because it was hard to get changed timely on those days. Resident #10 stated she was the Resident Council President and heard stories about residents being left wet and not changed timely, but she could not provide names of the residents. Resident #10 stated on 04/12/24 there was only one nurse and two aides working in the facility and the residents had to wait a long time for their care. Interview on 04/16/24 at 1:55 P.M. of the DON revealed on 04/12/24 night shift from 10:00 P.M. until 6:00 A.M. the nurse scheduled for the Assisted Living came to the nursing home side of the facility to work because the Assisted Living did not require a nurse to work night shift. The DON stated there were two nurses working on 04/12/24 from 10:00 P.M. until 6:00 A.M. Interview on 04/17/24 at 10:20 A.M. with LPN #100 confirmed on 04/12/24 on night shift he was the only nurse working in the facility. LPN #100 stated LPN #119 called off for the night shift and she was not replaced with another nurse. LPN #100 stated LPN #115 who worked the day shift stayed until 9:00 P.M. to help out, but he was the only nurse on 04/12/24 at 9:00 P.M. until 04/13/24 at 6:00 A.M. LPN #100 stated it was hard to be the only nurse in the facility because when there were 38 residents and an emergency situation happened it would put him in a bad situation. LPN #100 stated he worked as the only nurse on several Friday nights recently because the nurse that used to work on Friday nights quit and had not been replaced. LPN #100 stated the nurse assigned on 04/12/24 for night shift in the Assisted Living did not come to the nursing home side of the facility to work and help out. LPN #100 stated on 04/12/24 an STNA also called off work and that only left two aides in the facility working night shift from 10:30 P.M. until 6:30 A.M. LPN #100 stated on 04/12/24 there was one nurse and two aides working night shift. 5. Review of Resident #6's medical record revealed an admission date of 01/10/20 and diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, and vascular dementia, unspecified severity with other behavioral disturbances. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 was always incontinent of urine and bowel. Resident #6's upper and lower extremities had impairment on both sides, Resident #6 used a wheelchair, and Resident #6 was dependent for toileting hygiene. Review of Resident #6's care plan with a target date of 05/28/24 included Resident #6 had episodes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 11 of 17 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 04/17/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of bladder and bowel incontinence related to diagnoses and impaired mobility. Resident #6 would be at a reduced risk for complications through the next review and Resident #6 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to assist Resident #6 with toileting needs. Observation on 04/15/24 at 5:26 A.M. revealed State Tested Nursing Assistant's (STNA)'s #105 and #112 entered Resident #6's room to provide incontinence care. Resident #6's bathroom did not have a trash can in it and a dirty incontinence brief was lying on the bathroom floor. STNA #105 stated the dirty incontinence brief was lying on the floor in the bathroom when they arrived for work on 04/14/24 at 6:30 P.M. STNA #105 stated an STNA called off work and that left only STNA #105 and #112 to care for 36 residents. STNA #105 indicated only having two STNA's working made it hard to properly do their job, they were busy taking care of residents and did not have time to clean up the dirty incontinence brief. STNA #105 stated the incontinence brief should not have been left on the bathroom floor. Review of the facility policy titled Resident Rights revised 02/2021 included resident's had the right for communication with and access to people and services, both inside and outside the facility. This deficiency represents non-compliance investigated under Complaint Number OH00152225. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 12 of 17 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 04/17/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #21 and #23 received water timely and per their preference. This affected two residents (Resident #21 and #23) out of three residents reviewed for receiving water timely and had the potential to affect 12 residents (Resident's #1, #2, #3, #6, #8, #13, #17, #21, #23, #26, #27, #30) residing on the 200 nursing unit. The facility census was 36. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 04/01/21 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic nephropathy, and a personal history of urinary tract infections. Review of Resident #21's Quarterly Nutrition Evaluation dated 07/17/23 included Resident #21's diet order was low concentrated sweets, no added salt. Resident #21 was at risk for dehydration. Further review revealed to encourate fluids with and between meals for Resident #21, and might need to prompt, remind, cue and, or present fluids to Resident #21 to assure adequate fluid intake and hydration status. Review of Resident #21's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 required partial to moderate assistance to roll left and right, required supervision or touching assistance to walk ten feet, and was dependent to walk fifty feet with two turns. Review of Resident #21's care plan with a review date of 06/09/24 included Resident #21 prefered two cups of ice water at times. Resident #21's preferences would be honored. Interventions did not include an intervention for Resident #21's preference of having two cups of ice water. Observation on 04/15/24 at 1:41 P.M. of Resident #21 revealed she was lying in her bed with the head of her bed elevated. There was a styrofoam cup in front of Resident #21 on the bedside table, and there was no date written on the cup. Interview on 04/15/24 at 1:41 P.M. with Resident #21 revealed she did not get water today, and the nurse brought her water after she asked and Resident #21 pointed to the styrofoam cup in front of her. Resident #21 stated she wanted two cups of ice water on day shift, one cup of ice water with breakfast, then one cup of ice water between breakfast and lunch. Resident #21 indicated she did not get two cups of ice water at the times she preferred, and did not get any water at all until she asked the nurse to provide it. Resident #21 indicated she would be happy if she received two cups of ice water at breakfast and between breakfast and lunch. Resident #21 stated bedtime was horrible, I like to have water at night and I do not get it. Resident #21 indicated there were not enough State Tested Nursing Assistants (STNA)s to take care of the residents. Resident #21 stated she often did not get ice water in the morning as she preferred and requested. Interview on 04/15/24 at 1:41 P.M. with STNA #110 revealed she did not pass water to the residents in her assignment today and Resident #21 was part of her resident assignment. STNA #110 confirmed Resident #21 did not receive ice water today since she arrived for work at 6:30 A.M. STNA #110 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 13 of 17 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 04/17/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she had 14 or 15 residents to take care of today, over half of them required total care, and she was behind all day. STNA #110 said she made sure the residents who needed their incontinence briefs changed had that completed first and she did not always get water passed. STNA #110 stated sometimes she was just running from resident to resident trying to take care of them. Interview on 04/15/24 at 2:25 P.M. with Ombudsman #128 revealed in the past couple weeks she brought the problem of ice water not getting passed to the residents to the attention of the Administrator and the Director of Nursing (DON) more than one time. Ombudsman #128 stated both the Administrator and the DON walked to the resident rooms with her, including Resident #21, and verified with the resident no water was passed that day. Ombudsman #128 stated the DON told her she was going to have an in-service soon and include ice water distribution in the in-service education and have staff sign off they were aware ice water needed to be passed to the residents. Interview on 04/16/24 at 2:30 P.M. with the Administrator revealed water might not get passed in the morning, but the STNA's shift was not over yet and water would be passed before the STNA's left for the day at 6:30 P.M. The Administrator stated he was aware Resident #21 often did not have ice water given to her in the morning per her preference. Interview on 04/16/24 at 1:55 P.M. with the Director of Nursing (DON) confirmed she was aware Resident #21 often did not receive ice water and had talked to the STNA's about it, and had called to remind the aides to give ice water to Resident #21. The DON stated she was aware Resident #21 did not receive ice water today. The DON indicated the aides shift was not over yet and Resident #21 could ask the aides to give her ice water. Review of the 200 nursing unit census STNA #110 was assigned to revealed 12 residents (Resident's #1, #2, #3, #6, #8, #13, #17, #21, #23, #26, #27, #30) resided on the unit. Review of the facility policy titled Encouraging Fluids revised 10/2010 included the purpose of the procedure was to provide the resident with amount of fluids necessary to maintain optimum health. This might include encouraging fluids. Take the fluid container in the resident's room, inform the resident you have brought him or her a drink and encourage the resident to drink the fluid. 2. Review of Resident #23's medical record revealed an admission date of 10/26/20 and diagnoses included unspecified psychosis not due to a substance or known physiological condition, dementia with other behavioral disturbance, psychotic disorder with delusions due to known physiological condition. Review of Resident #23's Annual MDS 3.0 assessment dated [DATE] revealed Resident #23 had moderate cognitive impairment. Resident #23 used a wheelchair and required partial to moderate assistance to roll right and left and Resident #23 was not able to walk. Review of Resident #23's care plan with a target date of 06/28/24 included Resident #23 was at increased risk for altered nutritional status including Resident #21 needed alternate fluid consistency and was on a diuretic. Resident #23 would be free of signs and symptoms of dehydration. Interventions included to encourage and provide intake of fluids throughout the day, and might need to prompt, remind, cue, and or present fluids to Resident #23 to help assure adequate fluid intake and hydration status. Review of Resident #23's Comprehensive Nutritional Evaluation dated 03/19/24 included Resident #23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 14 of 17 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 04/17/2024 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was on a regular diet, regular consistency. Resident #23 was at risk for dehydration, and Resident #23's estimated fluids were 2525 cc's (cubic centimeters) per day. Continued on diuretic therapy, fluids to be encouraged with and between meals. Might need to prompt, remind, cue, and, or present fluids to Resident #23 to help assure adequate fluid intake and hydration status. Observation on 04/15/24 at 1:08 P.M. of Resident #23 revealed she was lying in bed with the head of the bed elevated. A styrofoam cup, undated was sitting on a bedside table in front of Resident #23. Interview on 04/15/24 at 1:08 P.M. with Resident #23 revealed she did not have water passed to her by the aides today. Resident #23 stated the styrofoam cup was from last night, no aides had given her water including ice water today, and she would like to have some ice water. Interview on 04/15/24 at 1:41 P.M. with STNA #110 revealed she did not pass water to the residents in her assignment today and Resident #23 was part of her resident assignment. STNA #110 confirmed Resident #23 did not receive ice water today since she arrived for work at 6:30 A.M. STNA #110 stated she had 14 or 15 residents to take care of today, over half of them required total care, and she was behind all day. STNA #110 said she made sure the residents who needed their incontinence briefs changed had that completed first and she did not always get water passed. STNA #110 stated sometimes she was just running from resident to resident trying to take care of them. Interview on 04/16/24 at 2:30 P.M. with Administrator revealed water might not get passed in the morning, but the STNA's shift was not over yet and water would be passed before the STNA's left for the day at 6:30 P.M. Interview on 04/16/24 at 1:55 P.M. with Director of Nursing (DON) confirmed she was aware the residents often did not receive ice water and had talked to the STNA's about it, and had called to remind the aides to distribute ice water to the residents. The DON stated the residents could ask for ice water to be brought to them instead of waiting for the aides to bring the water. Review of the 200 nursing unit census STNA #110 was assigned to revealed 12 residents (Resident's #1, #2, #3, #6, #8, #13, #17, #21, #23, #26, #27, #30) resided on the unit. Review of the facility policy titled Encouraging Fluids revised 10/2010 included the purpose of the procedure was to provide the resident with amount of fluids necessary to maintain optimum health. This might include encouraging fluids. Take the fluid container in the resident's room, inform the resident you have brought him or her a drink and encourage the resident to drink the fluid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 15 of 17 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 04/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, record review and review of the facility policy the facility failed to ensure a sanitary kitchen. This had the potential to affect all 36 of 36 residents residing in the facility. Residents Affected - Many Findings include: Observation on 04/15/24 at 7:05 A.M. of the kitchen with Dietary Director (DD) #131 revealed two large packages of frozen ground meat were placed in a large sink full of cold water. There was no observation of running water used to thaw the frozen meat. DD #131 confirmed the frozen meat was in the sink of cold water and no water was running into the sink where the frozen meat was. Observation on 04/15/24 at 7:10 A.M. with [NAME] #132 of the cooler in the kitchen revealed a metal rack was placed in the middle of the cooler and a tray on the metal rack full of small plastic containers with pears in most of the cups and cottage cheese in a smaller amount of cups revealed none of the small plastic containers had lids or plastic wrap covering them. Further observation revealed the small plastic containers were undated. [NAME] #132 confirmed the food in the small plastic containers was undated and not covered because the facility ran out of lids. [NAME] #132 stated something like plastic wrap should have been used to cover the pears and cottage cheese and she would discard all the food in the undated and uncovered containers of food. Observation on 04/15/24 at 7:20 A.M. with Dietary Aide #133 of the frozen meat in the large sink with cold water confirmed there was no running water used to thaw the meat while it was in the sink full of water. When asked if this was how frozen meat was usually thawed out Dietary Aide #133 stated yes Observation on 04/15/24 at 7:46 A.M. of the breakfast meal tray line revealed Dietary Aide (DA) #133 repeatedly touching her face and rubbing her eyes then picking up a resident meal tray and placing it on the metal delivery cart. There was no observation of DA #133 washing her hands or using hand sanitizer during the breakfast tray line. DA #133 confirmed she kept touching her face then picking resident trays up and placing the trays on the metal cart, and stated I try really hard not to do that. DA #133 stated her eyes were itching because she forgot to take her eye make-up off last night. DA #133 confirmed she did not use hand sanitizer or wash her hands during the breakfast tray line. Observation on 04/15/24 at 8:10 A.M. of State Tested Nursing Assistant (STNA) #104 revealed she picked up a breakfast meal tray off the metal cart and took it into Resident #15's room and assisted with meal tray set-up, left the room and without using hand sanitizer or washing her hands she picked up Resident #24's meal tray and took it into Resident #24's room and assisted Resident #24 with meal set-up. Without using hand sanitizer or washing her hands STNA #104 walked out of Resident #24's room, over to the metal cart and picked up Resident #18's meal tray and took it in Resident #18's room and assisted her with meal set-up. Without using hand sanitizer or washing her hands STNA #104 walked out of Resident #18's room and over to the metal cart and was preparing to pick up another resident meal tray when the surveyor stopped her. STNA #104 confirmed she did not use hand sanitizer or wash her hands between delivering Resident #15, #24 and #18's meal trays. STNA #104 stated I did not think I had to use hand sanitizer when I was passing out meal trays. Interview on 04/15/24 at 9:12 A.M. with Registered Dietician (RD) #134 revealed it was not the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 16 of 17 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 04/17/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many correct procedure to thaw meat in a sink full of water without having running water in the sink where the meat was. RD #134 stated the STNA's should use hand sanitizer between every resident when serving meal trays, and should wash their hands after every third tray. Review of the facility policy titled Food Preparation and Service revised 04/2019 included food and nutrition services employees prepare and serve food in a manner that complied with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Thawing procedures included to completely submerge the item in cold running water. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Review of the 2019 Food Code Chapter 3717-1-03 Reference Guide Food included frozen food must be thawed under refrigeration at 41 degrees Fahrenheit or less, under running water of 70 degrees Fahrenheit or less, or during the cooking process. This deficiency represents non-compliance investigated under Complaint Number OH00152225. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365858 If continuation sheet Page 17 of 17