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.
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 3
Event ID:
366158
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
366158
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion Rehabilitation and Nursing Center
13900 Bennett Road
North Royalton, OH 44133
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366158
If continuation sheet
Page 2 of 3
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
366158
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pavilion Rehabilitation and Nursing Center
13900 Bennett Road
North Royalton, OH 44133
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366158
If continuation sheet
Page 3 of 3
