Health inspection·May 15, 2024

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of personnel files and staff interview, the facility failed to ensure state tested nurse aides (STNAs) were given a performance review at least every 12 months as required. This affected one (#201) of two STNA personnel files reviewed that were employed more then one year at the facility and had the potential to affect all 43 residents residing in the facility. The facility census was 43. Residents Affected - Many Findings Include: Review of the personnel file for STNA #201 revealed a hire date of 07/01/22. Further review of the personnel file contained no evidence of a performance review completed every 12 months as required. Interview on 05/13/24 at 2:20 P.M. with Human Resource Director (HRD) #450 verified the facility did not complete a performance review for STNA #201 every 12 months as required. Page 1 of 3 366158 366158 05/15/2024 The Pavilion Rehabilitation and Nursing Center 13900 Bennett Road North Royalton, OH 44133

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. 366158 Page 2 of 3 366158 05/15/2024 The Pavilion Rehabilitation and Nursing Center 13900 Bennett Road North Royalton, OH 44133

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. 366158 Page 3 of 3