Inspection visit

Health inspectionJune 26, 2024

THE PAVILION REHABILITATION AND NURSING CENTERCMS #3661585 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure Resident #50 and their resident representative had access to personal records upon request. This affected one resident (Resident #50) of four residents reviewed for resident rights. The facility census was 49. Findings include: Review of the closed medical record for Resident #50 revealed Resident #50 was admitted to the facility on [DATE] and discharged to another facility on 04/23/24. Medical diagnoses included rhabdomyolysis, chronic obstructive pulmonary disease, cirrhosis of the liver, cognitive communication deficit and schizoaffective bipolar. Review of the admission Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition with a Brief Interview Mental Status score of 15 out of 15. Resident #50 needed set up and clean up assistance to eat, and was independent for oral hygiene, toilet hygiene, rolling back on the bed, sitting on the side of the bed, and laying back in the bed. Resident #50 was also independent to sit to stand, transfer from the bed to the chair, transfer to the shower, walk ten feet and walk 50 feet. Review of the document titled Unlimited Durable Power of Attorney (POA) , dated and notarized on 01/21/21, revealed Resident #50 appointed Family Member #364 as the true and lawful Attorney-in-Fact over medical care and finances for Resident #50. Review of the document titled Request For and Authorization To Release Health Information, dated 02/06/24, revealed Resident #50 had signed the request on 02/06/24 to permit the facility and Former Social Worker (FSW) #358 to receive Resident #50's health information from the VA (veterans administration) Northeast Ohio Healthcare System. The authorization did not expire until 12/31/24. An interview was conducted on 06/25/24 at 9:50 A.M. with FM #364 revealing Resident #50's birth certificate, social security card, state identification card and his DD214 military discharge papers were being held in FSW #358's office in a file at the facility. FM #364 stated he was informed by FSW #358 that Resident #50 had signed a release to receive his personal medical information from the VA which FSW #358 had received at the facility. FM #364 stated Resident #50 verbally requested his personal file of information be given to him prior to his discharge and FM #364 was the POA and also requested to have Resident #50's personal information that was left in FSW #358's office but the administrator refused to provide it to them. (continued on next page) 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 8 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 06/26/2024 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 06/26/24 at 12:16 P.M. with Ombudsman #900 who reported having an open misappropriation case against the facility regarding Resident #50 missing important personal government issued documents and poor communication from the facility to FM #364. The Ombudsman stated Resident #50's social security card and state identification cards were lost. An interview conducted on 06/26/24 at 1:33 P.M. with the Administrator revealed Resident #50 requested his personal documents but the Administrator was unsure if Resident #50's social security card, military identification and birth certificate were in the personal file. The Administrator stated the facility had no standard procedure for receiving and storing resident information when received by staff. The Administrator verified he looked with the Ombudsman and no personal documents were found. The Administrator verified he did not give the file stored in the FSW #358's desk to Resident #50 or FM # 364. An interview was conducted on 06/26/24 at 2:31 P.M. with FSW #358 via telephone and revealed all of Resident #50's personal information given to her was to be returned to Resident #50 upon verbal request. FSW #358 verified military documents and government issued forms of identification were in a file she had had in her office at the facility. FSW #358 verified the Administrator would not give FM #364 any of that information even though FM #364 had provided FSW #358 multiple envelopes of information to be stored in that personal file which was to be returned to Resident #50 or the POA/FM#364 upon discharge from the facility. FSW #358 verified FM #364 did sign a release of information form and explained this to the Administrator. FSW #358 verified Resident #50 had good cognition and was able to make requests verbally or in writing. Review of the facility policy titled Release of Information, dated November 2019, revealed resident records, whether medical, financial or social in nature were safeguarded to protect the confidentiality of the information. The resident may initiate a request to release such information contained in the records and charts to any they wish. Such request will be honored only upon the receipt of a written signed and dated request from the resident or representative. This deficiency represents non-compliance investigated under Complaint Number OH00154586. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 2 of 8 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 06/26/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interviews and facility policy review, the facility failed to ensure an adequate supply of clean towels and washcloths for resident care were available to maintain the residents right to a safe, clean, comfortable and homelike environment. This affected 31 residents (#3,#4,#5,#6,#8,#9,#10,#11,#13,#17,#18,#20,#21,#22,#23,#26,#27,#28,#29,#31,#32,#35,#36,#37,#38,#41,#43,#45,#46,#4 and #48) residing on the 200/300 units out of 49 residents residing in the facility. The facility census was 49. Findings include: An environmental tour was conducted on 06/25/24 between 10:49 A.M. and 11:09 A.M. The tour revealed unit 200 clean linen room was empty of clean towels and washcloths for resident care. Unit 300 clean linen room had three washcloths available for resident care and no clean towels were available. The second Unit 300 clean linen room had three washcloths and two bath towels available for resident care. Interview on 06/25/24 at 10:49 A.M. with Regional Director (RD) #363 verified the short supply of lines available for resident use and stated the clean linen room Unit 200 would be restocked. Observation on 06/25/24 at 12:38 P.M. revealed Unit 200 clean linen room had no shower towels available and a stack of 25 washcloths were replenished. Interview on 06/25/24 at 10:36 A.M. to 10:55 A.M. with State Tested Nurse Assistant ( STNA) #311, # 319, #312 and Registered Nurse ( RN) #327 revealed the clean linen supply was short for resident care. Interview on 06/25/24 at 10:57 A.M. STNA # 310 stated low linens could affect resident shower days. Interview on 06/25/24 at 11:05 A.M. revealed Resident #27 missed a shower day due to no shower towels being available. Resident #27 stated he felt terrible about not getting his shower. Interview on 06/25/24 at 12:54 P.M. with Laundry Aid # 349 revealed there were nine dry shower towels available for resident use and 12 towels were drying at the time of interview. LA#349 stated nurses on the floor would use bibs for washcloths if supply was low. LA #349 also stated she could not order the amount of linen needed due to budget requirements. Interview on 06/25/24 at 1:26 P.M. with Central Supply Supervisor # 304 revealed the facility ordered non-medical supplies only off what was needed, and no-par levels were used. Interview on 06/25/24 at 2:24 P.M. with Housekeeping Supervisor # 348 stated the par level of linens should be double the resident census in house, and the Administrator was responsible to approve orders for non-medical supplies such as linens and towels. Interview on 06/25/24 at 4:47 P.M. with the Administrator revealed towels and washcloths were ordered on an as needed basis, and all orders need to be approved by corporate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 3 of 8 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 06/26/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Quality of Life Homelike Environment dated May 2017 revealed residents were to be provided with a safe , clean, comfortable and homelike environment which include clean bed and bath linens in good shape, and a clean , sanitary, and orderly environment. This deficiency identified non-compliance during the investigation of Complaint Number OH00154466. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 4 of 8 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 06/26/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on record review and interview the facility failed to provide sufficient support personnel to effectively carry out the functions of food and nutrition services. This had the potential to affect all 49 residents receiving meals from the kitchen, as the facility did not identify any residents who did not eat by mouth. The facility census was 49. Findings include: Review of facility document titled Facility Assessment, dated 05/27/24, revealed food and nutrition services was overseen by a full-time dietary manager and a contracted dietitian. The kitchen was staffed by cooks and dietary aids. Staffing plan included one full time dietary manager, a part time dietitian and five full time food service workers and three part time food service workers. Review of the Dietary Services Schedule dated 05/30/24 to 06/12/24 revealed five full-time dietary employees were scheduled and one part-time employee scheduled to work. Review of Dietary Services Schedule dated 06/13/24 to 06/26/24 revealed five full-time dietary employees and two part time employees were available to work. Review of Dietary Services Schedule dated 06/27/24 to 07/10/24 revealed six full time dietary employees were available to work and one part time employee was available to work. Interview on 06/25/24 at 4:47 P.M. with the Administrator verified there was not enough part-time employees scheduled in dietary according to the Facility Assessment. Interview on 06/25/24 at 11:00 A.M. with Resident # 37 revealed breakfast was to be served at 7:30 A.M. but did not come until 9:30 A.M. Interview on 06/25/24 at 11:05 A.M. with Resident # 27 revealed there had been long wait times for breakfast to arrive some days. Interview on 06/25/24 at 11:10 A.M. with Dietary Aid (DA) #342 revealed dietary staff did not stay over to the next shift if staff was low in the kitchen because of no pay incentives. DA #342 revealed the nurse aides had to work in the kitchen when needed because there were not enough dietary employees and the nurse aides did not uphold all food production protocols. Interview on 06/25/24 at 2:44 P.M. with the Regional Culinary Director (RCD) #355 verified state tested nurse aids did fill in if the dietary department was short staffed. Interview on 06/26/24 at 12:57 P.M. with Dietary Manager (DM) #340 revealed she was off for six weeks to recover from surgery. The facility did not fill in the dietary staff schedule therefore cook # 341 worked double shifts for many days. DM #340 said she would fill in where needed in the kitchen when she was on duty. Review of the policy titled Staffing dated April 2007 revealed the facility provided adequate staffing to meet needed care and services for resident population. Certified nursing assistants were available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Other support services such as dietary, activities, social, therapy and environmental were adequately staffed to ensure resident's needs were met. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 5 of 8 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 06/26/2024 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 0802 This deficiency identified non-compliance during the investigation for Master Complaint Number OH00154970. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 6 of 8 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 06/26/2024 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 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 facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 49 residents receiving meals from the facility kitchen, as the facility identified no residents as receiving nothing by mouth. The facility census was 49. Findings include: Observation during the initial kitchen tour on 06/25/24 between 11:09 A.M. and 12:28 P.M. with Regional Culinary Director (RCD) #355 revealed the following concerns: • The kitchen floor had debris in the corners and edges, with a buildup of dirt and grime on the floor. • Observation of dry food storage area revealed opened and undated bread, confection sugar not sealed in a paper bag and not dated, a box of sugar stored in an open cardboard box not dated with a scoop stored in the box of sugar, chicken gravy packets were undated, a 50-pound bag of long grain rice was unsealed with scoop stored in the bag on the bottom shelf storage. Also, the dry food storage floor revealed dried whole onion peel debris on the floor with a bug crawling through the peels. • In the dairy walk-in cooler was observed to have food debris under the cooler shelving. • Observation of the freezer revealed a thin layer of ice buildup on the floor of the freezer with a large buildup of ice on the ceiling of the freezer. An undated open plastic bag of country fried steak and hush puppies were observed. At the time of observation , RCD #355 confirmed the areas of concern. Review of the undated facility policy titled Food Storage revealed food was to be stored and prepared with professional standards to prevent contamination. Metal or plastic containers with tight fitting covers would be used to store flour, sugar and broken lots of bulk foods. All containers must be accurately labeled. This deficiency was an incidental finding under Complaint Number OH00154970. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 7 of 8 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 06/26/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain commercial laundry machines in safe operating condition. This had the potential to affect all 49 residents living in the facility. The facility census was 49. Residents Affected - Many Findings include: Observation on 06/25/24 at 12:54 P.M. revealed one small Unimac commercial laundry machine was in use. The large Unimac commercial laundry machine was not in use. Interview on 06/25/24 at 12:54 A.M. with Laundry Aid (LA) #349 revealed on 06/13/24 the large Unimac commercial laundry machine lost power and stopped working. The small Unimac commercial washing machine was not repaired and was unable to be used. The facility had no commercial laundry machine for resident care; therefore, the maintenance supervisor drove the soiled laundry to a sister facility. On 06/14/24 the small Unimac commercial washing machine was repaired but was advised by the repair technician not to use the large Unimac commercial machine because of wiring issues. LA #349 stated they have told the facility the small Unimac washing machine needed fixed. LA #349 verified there was no back up commercial laundry machine to use in the facility for resident laundry. Interview on 06/25/24 at 3:47 P.M. with Director of Maintenance (DOM) #347 revealed the small Unimac washing machine had not been in use since January of 2024. The small Unimac washing machine could not be fixed because a part was needed and the facility did not have the part. DOM #347 verified the facility had him transfer the soiled laundry in his car to a sister facility to be washed for resident care. DOM #347 verified the large Unimac commercial washing machine was not in use because Belenkey repair technician advised against use. Interview on 06/25/24 at 3:28 P.M. with the Director of Nursing (DON) revealed some resident's clothing was returned late because the facility washing machine was broken. Interview on 06/25/24 at 4:47 P.M. with the Administrator revealed he was only informed the large commercial washing was down and was not aware the small commercial washing machine needed repaired at the time. Review of facility sales and security agreement dated 06/20/24 revealed [NAME] Laundry Service informed the facility to replace the large Unimac commercial machine because the slab under the large machine was moving and had come free. Review of policy titled Maintenance Service dated December 2009 revealed maintenance service would be provided to all areas of the building, grounds and equipment. This deficiency represents non-compliance investigated under Complaint Number OH00154970. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366158 If continuation sheet Page 8 of 8

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0573GeneralS&S Dpotential for harm
F573 - The resident has the right to access personal and medical records pertaining
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
0802GeneralS&S Fpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0908GeneralS&S Fpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
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.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the June 26, 2024 survey of THE PAVILION REHABILITATION AND NURSING CENTER?

This was a inspection survey of THE PAVILION REHABILITATION AND NURSING CENTER on June 26, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE PAVILION REHABILITATION AND NURSING CENTER on June 26, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Let each resident or the resident's legal representative access or purchase copies of all the resident's records."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 26, 2024