Health inspection·November 6, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure call lights were within reach and accessible to residents. This affected three residents (#11, #12, and #36) of six residents reviewed for call light placement. The facility census was 44. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record revealed an admission date of 08/09/24 with diagnoses that included, but not limited to, cerebral infarction, muscle weakness, difficulty in walking and glaucoma. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 09/04/24, revealed Resident #11 was cognitively intact and required staff assistance for all activities of daily living (ADLs). Observation on 11/06/24 at 8:32 A.M. revealed Resident #11 was lying in bed. The call light was on the floor and not within the resident's reach. 2. Review of Resident #12's medical record revealed an admission date of 08/30/24 with diagnoses that included, but not limited to, muscle weakness, difficulty in walking and amaurosis fugax (a painless temporary loss of vision in one or both eyes). Review of the most recent MDS 3.0 assessment, dated 09/06/24, revealed Resident #12 was cognitively intact and required staff assistance for all ADLs. Observation on 11/06/24 at 8:32 A.M. revealed Resident #12 was lying in bed. The call light was on the floor and not within the resident's reach. Interview on 11/06/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #134 verified Resident #11 and Resident #12's call lights were out of reach of the residents. 3. Review of Resident #36's medical record revealed and admission date of 09/03/19 and a readmission date of 12/06/20. Diagnoses included, but not limited to, abnormal posture, muscle weakness, unspecified fracture of the lower end of the right femur, morbid (severe) obesity due to excess calories, age-related physical debility, unspecified osteoarthritis, difficulty in walking and need for assistance with personal care. Review of the most recent MDS 3.0 assessment, dated 10/03/24, revealed Resident #36 was moderately cognitively impaired and required staff assistance for all ADLs. Observation on 11/06/24 at 8:15 A.M. revealed Resident #36 was lying in bed. The resident's call light was hanging on the call light electrical box, located on the wall behind the bed, and not within Resident #36's reach. Page 1 of 2 365858 365858 11/06/2024 The Pavilion at Stow for Nursing and Rehabilitatio 3700 Englewood Drive Stow, OH 44224

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/06/24 at 8:16 A.M. with Registered Nurse (RN) #143 verified Resident #36's call light was not within the resident's reach. Review of the facility policy titled Call System, Residents, dated September 2022, revealed each resident is provided with a means to call staff directly for assistance from his/her bed, toileting/bathing facilities and from the floor. This deficiency represents non-compliance investigated under Complaint Number OH00159079. 365858 Page 2 of 2