Health inspection·May 15, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to ensure ensure foods were stored in a manner to prevent contamination and spoilage. This had the potential to affect all 43 residents. The facility census was 43. Findings include: Tour of the facility kitchen on 05/14/24 between 9:35 A.M. and 9:57 A.M. with [NAME] (CK) #400 revealed the oven hood suppression system was coated in a layer of brown and black grease and the side of the grease collection area was coated in thick chunky grease. Observation of the walk-in refrigerator revealed the lettuce was significantly brown in color and had a best buy date of 04/20/24, a bag of carrots was opened with a best buy date of 04/18/24, a bag of pepperoni was open and had no date, a canister of cooked hamburger patties and hot dogs were undated and uncovered, a plastic container of meat sauce had a label sticker of 02/15/23, and a half of a watermelon was in plastic wrap with no date. Observation of the walk-in freezer revealed a bag of omelettes and a bag of cream puffs were open and undated. Interview with CK #400 during the tour of the kitchen on 05/14/24 between 9:35 A.M. and 9:57 A.M. confirmed the above findings at the time of observation. Review of the undated policy titled, Food Storage, revealed food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. 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 05/15/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview, the facility failed to maintain the laundry area in clean, safe, and sanitary condition. This had the potential to affect all 43 residents. The facility census was 43 residents. Residents Affected - Many Findings Include: Observation of the facility laundry area with Laundry Director (LD) #150 at 9:59 A.M. on 05/13/24 revealed two industrial-sized washers were in use and the area behind the dryers was covered in lint up and down the backs of the machines and the power cords were visibly encased in lint debris. There was also a household-sized dryer in use and the dryer ventilation system leading up to the housing was held together with dry wall spackle. Observation of the ceiling tiles in the laundry room revealed multiple tiles were significantly water stained, and above the clean linen area was a water stained ceiling tile that was brown in color and was sagging down multiple inches. Interview with LD #150 on 05/13/24 at 9:59 A.M., during observation of the laundry area, confirmed the above findings at the time of discovery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 3 of 3