Health inspection·December 7, 2022

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Resident #204's personal funds were forwarded to the resident's estate within 30 days. This affected one resident (Resident #204) of one resident reviewed for personal funds after death. Residents Affected - Few Findings include: Review of the medical record for Resident #204 revealed an admission date of 04/17/22 with a diagnosis of Alzheimer's disease. She passed away on 04/17/22. Review of Resident #204's personal funds statement dated 12/05/22 revealed on 04/18/22 she had a balance of $12.25. The facility closed her account on 04/18/22. A check was made out to Resident #204 in the amount of $12.25 and was dated for 06/06/22 and cleared the facility's bank on 07/11/22. Interview on 12/06/22 at 12:20 P.M. with the Business Office Manager (BOM) #504 verified Resident #204 passed away on 04/17/22 and personal funds were not dispersed to the resident's estate until 06/06/22. She verified this was over 30 days. Page 1 of 4 366271 366271 12/07/2022 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure resident assessments were completed timely. This affected three (Residents #26, #34 and #49) of three residents reviewed for resident assessments. The facility had a census of 51 residents. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 04/25/21 with diagnoses including hypertension and depression. Review of the Minimum Data Set (MDS) assessments for Resident #26 revealed she had quarterly assessments on 07/25/22 and 11/18/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months. 2. Review of the medical record for Resident #34 revealed an admission date of 03/15/22 with diagnoses including diabetes mellitus and hypertension. Review of the Minimum Data Set (MDS) assessments for Resident #34 revealed he had a quarterly assessment completed on 07/19/22. The next assessment was in progress and dated 11/23/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months. 3. Review of the medical record for Resident #49 revealed an admission date of 03/10/22 with diagnoses including Alzheimer's disease, diabetes mellitus and congestive heart disease. Review of the Minimum Data Set (MDS) assessments for Resident #49 revealed he had a quarterly assessment on 07/07/22. The next scheduled quarterly assessment was in progress and dated 12/08/22. Interview on 12/05/22 at 1:52 P.M. with Registered Nurse (RN) #500, verified the MDS dates were not done timely and should have been completed at least every three months. 366271 Page 2 of 4 366271 12/07/2022 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of meeting minutes, the facility failed to serve palatable food at an appetizing temperature. This affected all 51 residents in the facility. Residents Affected - Many Findings include: During the initial screening, Resident's #5 and #16 on 12/04/22 beginning at 11:12 A.M. reported the food was often cold and of poor quality. Observation of the dinner meal on the South unit on 12/04/22 at 5:00 P.M. revealed multiple residents complained the meal did not look appetizing, the meat was of poor poor quality. The menu indicated the meal was a hot hamburger sandwich with brown gravy, mashed potatoes and carrots. The thin dotted hamburger patty was on top of a piece of bread and covered in brown gravy. Three residents requested the substitution after receiving their meal. The posted substitution was a fish sandwich. An aide called the kitchen requesting fish sandwiches. The aide then informed the residents the kitchen did not have the fish sandwiches and offered them a choice of chicken nuggets or grilled cheese. Several asked for the chicken nuggets. Then the residents were informed the kitchen did not have chicken nuggets. The residents verbalized they were upset with this and indicated this occurred with some frequency. On 12/06/22 at 11:35 A.M. the food temperatures of items in the steam table were above the required temperatures. The pork with peaches were 194 degrees Fahrenheit (F), mechanical soft pork 198 F, pureed pork 202 F, baked beans 201 F, vegetables 174 F, pureed vegetables 196 F and hamburger patties 165 F. A test tray was requested for the South unit. Foods were plated and covered with a thermal dome but not on a thermal bottom. Interview with State Tested Nurse Aides (STNA) #506 and #507 and Licensed Practical Nurse (LPN) #505 all reported residents complained daily of the quality of the food, not receiving the food on the menu because it was not available, not following the menu, not providing the residents coffee at each meal. The biggest concern in the facility was the food service. This information was shared with the Administrator on 12/04/22 at 5:37 P.M. The food cart arrived with the test tray on 12/06/22 at 11:49 A.M. This cart was for residents who ate independently however it contained two food trays for residents who required to be fed. All trays were served and assistance provided by 12:09 P.M. when the test tray was conducted. The test tray was conducted with Registered Dietitian (RD) #501 on 12/06/22 at 12:09 P.M. RD #501 took the temperature of the pork and said it was over 140 F and pulled out the thermometer quickly. The thermometer was observed to read 110 F. She was requested to place the thermometer back into the pork. The temperature measured 105 F. The pork was tasted and it was barely luke warm but had good flavor. The vegetables were 97.2 F and were cold and not appetizing. RD #501 was asked about not using the thermal bases observed in the kitchen. She reported there were not enough for each resident. Interview with the Administrator on 12/06/22 at 4:30 P.M. verified there were not enough thermal bases for the plates and that would help to keep the food warm. Review of the concern log and resident council minutes revealed on 04/21/22 residents voiced they strongly disliked the food supplier and requested a change in supplier, 06/16/22 would like fresh fruit more often, 07/21/22 noticing coffee grounds in the coffee, 08/22/22 requesting the return of the food committee and 09/15/22 reported the meals were cold. 366271 Page 3 of 4 366271 12/07/2022 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0804 Review of the food meeting minutes dated 09/15/22 at 1:30 P.M. residents want to see a slight change in the alternative menu, discussed with dietary manager, alternative menu: Level of Harm - Minimal harm or potential for actual harm Monday-Pizza Residents Affected - Many Tuesday-Hamburger/cheeseburger Wednesday-Bologna sandwich (fried or regular) Thursday-Chef salad Friday-Baked potato (cheese, sour cream, broccoli, bacon) Saturday-Egg salad Sunday-Fish sandwich Review of the food meeting minutes dated 10/20/22 at 1:30 P.M. indicated the staff in the kitchen were continuing to do the best job with making the good as good as possible for the residents. The alternative menu switched back to chicken nuggets on Wednesdays as not many residents have been ordering bologna sandwiches. Review of the food meeting minutes dated 11/22/22 at 1:30 P.M. revealed the facility was working on hiring a new dietary manager, discussed choice meal, the residents would have surprise sack bags for holidays like Christmas and thanksgiving, and wanted more homemade dessert. 366271 Page 4 of 4