Health inspection·November 26, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, record review and review of facility policy, the facility did not ensure a safe, functional, sanitary and comfortable environment for all residents. This had the potential to affect all 40 residents living in the facility. Findings include: Observations were conducted during a tour of the facility with the Administrator on 11/19/24 at 10:15 A.M. to 11:00 A.M. and revealed the following areas of concern with the physical environment: • In the elevator, which was the primary method for residents to get from the resident rooms and common areas on the second floor to the main floor, the carpet in the elevator was dirty with black, white and brown stains and the carpet was worn. • On the 100 wing there was a buildup of dirt along the baseboards in the hall. • In Resident #11 and 12's room there was a ceiling with chipped paint in the bathroom. • In Resident #13's room there was a build-up of dirt and debris behind the door, and the inside of the window jam had built up dirt and dead insects. The register and vents in the room had a heavy build-up of dust. • In Resident #45's room the shower was noted to be cracked at the base with a noted hole in it at the threshold. The floor in front of the shower was cracked. • The hall carpet on the 200 hall was bubbled up in the center in multiple places posing a potential (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 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 11/26/2024 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)