Health inspection·March 22, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected two residents (#29 and #41) of six residents whose rooms were observed. The facility census was 45. Findings include: Observation on 03/21/24 at 9:12 A.M. revealed Resident #29's bed railing had a large amount of a dried brown substance that appeared to be stool, a large pile of moldy food underneath the bed, and the floor was dirty and had scattered debris on it. The bathroom that was shared with Resident #41 had stool in the toilet and on the toilet seat and the floor was dirty and had debris on it. The observations were confirmed by State Tested Nursing Assistant #204 who indicated the observations would be reported to the housekeeper. An attempt to interview Resident #29 was unsuccessful; the resident was unable to answer questions appropriately. Interview on 03/21/24 at 1:10 P.M. with Housekeeper #245 revealed she tried to clean the resident rooms and common areas daily and stated she was not aware Resident #29 and #41's room needed cleaned. Housekeeper #245 had not observed Resident #29's dirty bed rail, moldy food underneath the bed or unclean bathroom. This deficiency represents non-compliance investigated under Complaint Number OH00151185. Page 1 of 3 366158 366158 03/22/2024 The Pavilion Rehabilitation and Nursing Center 13900 Bennett Road North Royalton, OH 44133

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation and interview the facility failed to ensure the timely identification and removal of expired drugs from current medication supply. This affected two (#22 and #42) of three residents observed for medication administration. Findings include: Observation of medication administration on 03/21/24 at 8:03 A.M. for Resident #22 with Licensed Practical Nurse (LPN) #226 revealed LPN #226 obtaining a bottle of Vitamin B6 with an expiration date of October 2023. LPN #226 administered one Vitamin B6 25 milligram (mg) from the expired bottle to Resident #22. Observation on 03/21/24 at 8:25 A.M. for Resident #42 with LPN #226 revealed LPN #226 obtaining a bottle of Vitamin B12 with an expiration date of November 2023 and a bottle of cranberry supplement with an expiration date of February 2024. LPN #226 administered Vitamin B12 1000 microgram (mcg) and the cranberry supplement from the expired bottles to Resident #42. The expiration dates of the administered vitamins and cranberry supplement were verified with LPN #226 and Regional Director of Operations on 03/21/24 at 9:42 A.M. LPN #226 stated she had not checked the expiration dates prior to administering the medications. This deficiency represents non-compliance investigated under Complaint Number OH00151185. 366158 Page 2 of 3 366158 03/22/2024 The Pavilion Rehabilitation and Nursing Center 13900 Bennett Road North Royalton, OH 44133

F 0759 Ensure medication error rates are not 5 percent or greater. 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, and policy review the facility failed to ensure a medication error rate of less than five percent. Two errors occurred within 26 opportunities for error resulting in a medication error rate of 7.6 percent. This affected two (#22 and #42) of three residents observed for medication administration. Residents Affected - Few Findings include: Observation of medication administration on [DATE] at 8:03 A.M. for Resident #22 with Licensed Practical Nurse (LPN) #226 revealed LPN #226 obtaining a bottle of Vitamin B6 with an expiration date of [DATE]. LPN #226 administered one Vitamin B6 25 milligram (mg) from the expired bottle to Resident #22. Observation on [DATE] at 8:25 A.M. for Resident #42 with LPN #226 revealed LPN #226 obtaining a bottle of Vitamin B12 with an expiration date of [DATE]. LPN #226 administered Vitamin B12 1000 microgram (mcg) from the expired bottle to Resident #42. The expiration dates of the administered vitamins were verified with LPN #226 and Regional Director of Operations on [DATE] at 9:42 A.M. LPN #226 stated she had not checked the expiration dates prior to administering the medications. Review of Resident #22's medical records revealed an admission date of [DATE]. Review of current physician orders for [DATE] revealed Resident #22 was ordered vitamin B6, 25 mg one time a day. Review of Resident #42's medical records revealed an admission date of [DATE]. Review of current physician orders for [DATE] revealed Resident #42 was ordered cyanocobalamin (Vitamin B12) 1000 mcg one time a day. Review of facility policy titled Administering Medications revised 12/12 revealed expiration dates must be checked prior to administering the medication. This deficiency represents non-compliance investigated under Complaint Number OH00151185. 366158 Page 3 of 3