Health inspection·June 18, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to ensure call lights were within resident reach. This affected two (#7 and #23) of two residents reviewed for call lights. The facility census was 44. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. required extensive to dependence for all activities of daily living, and was always incontinent of urine and bowel. Review of the care plan dated 03/18/25 revealed Resident #7 had self-care deficits for activities of daily living related to her diagnoses. Interventions included to provide bed mobility of two persons and encourage Resident #7 to use call light when assistance was needed. Observation on 06/16/25 at 9:59 A.M. revealed Resident #7 lying in bed hollering for help. Resident #7 was screaming I need someone to help me. Resident #7's call light button was hanging on the wall by the curtain approximately ten feet from her. Interview on 06/16/25 at 10:01 A.M. with Certified Nursing Assistant (CNA) #237 confirmed Resident #7's call button was not in reach. Review of the facility policy titled call system, residents, revised September 2022, revealed each resident was provided with a means to call staff directly for assistance from his/her bed and from toileting/bathing facilities. 2. Review of the medical record for Resident #23 revealed an admission date of 04/22/24. Diagnoses included chronic obstructive pulmonary disease, Parkinson's disease, and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and required extensive to dependence for all activities of daily living. Review of the care plan dated 04/17/25 revealed Resident #23 had a self-care deficit for activities of daily living related to his diagnoses. Interventions included to provide bed mobility of two persons and encourage Resident #23 to use a call light when assistance was needed. Page 1 of 12 366271 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/16/25 at 9:56 A.M. revealed Resident #23 sitting in a wheelchair in his room. Resident #23 was approximately five feet from his bed where his call light was positioned. Interview during the observation with the Director of Nursing (DON) confirmed that Resident #23's call light button was out of his reach. Review of the facility policy titled call system, residents, revised September 2022, revealed each resident was provided with a means to call staff directly for assistance from his/her bed and from toileting/bathing facilities. 366271 Page 2 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and interview the facility failed to ensure advanced directives had the appropriate signatures. This affected one resident (#8) of 17 residents (#15, #9, #46, #37, #28, #5, #40, #11, #16, #4, #1, #42, #22, #7, #12, #8, and #3) whose advanced directives were reviewed. The facility census was 44. Findings include: Review of the medical record for Resident #8 revealed an admission date of 05/16/25. Diagnoses included urinary tract infection, dementia, and prostate cancer. Review of Resident #8's physician orders for June 2025 revealed an active order for Do Not Resuscitate Comfort Care- Arrest (DNRCC-A) dated 05/16/25. Review of Resident #8's DNRCC-A form dated 05/16/25 revealed on the line for required signature of physician, APRN [advance practiced registered nurse], or PA [physician assistant] were the signatures of Assistant Director of Nursing (ADON) #102 and Licensed Practical Nurse (LPN) #134. Written on the line required for APRN or PA: name of the supervising physician (PA) or collaborating physician (APRN) for this patient and the physician's HNPI [national provider identifier], DEA [drug enforcement administration], or state medical license number was per Physician #300. Interview on 06/16/25 at 4:17 P.M. with the Administrator verified the physician, PA, or APRN did not sign Resident #8's DNRCC-A form. The Administrator stated the two nurses (ADON #102 and LPN #134) signed the form with the physician's verbal consent. 366271 Page 3 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage letters and staff interview, the facility failed to inform residents of the name and phone number of the Quality Improvement Organization (QIO). This affected one resident of one resident reviewed for liability notices (Resident #2). The census was 44. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed the resident was re-admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter, signed by the resident/resident representative on 12/18/24, revealed services ended on 12/20/24. The letter did not provide the necessary QIO information to request a timely appeal regarding the ending of skilled services and therapies. Interview on 06/16/25 at 3:30 P.M. with Social Service Coordinator #113 confirmed the Notice of Medicare Non-Coverage letter to Resident #2 did not provide the information needed for the appeal process. Interview on 06/16/25 at 3:37 P.M. with the Director of Nursing verified the Notice of Medicare Non-Coverage provided to Resident #8 did not have the name or telephone number to appeal the discharge date . 366271 Page 4 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete Significant Change in Minimum Data Set (MDS) status assessments within 14 days after hospice admission date. This affected three residents (#16, #17 and #42) of nine reviewed for hospice services. Facility census was 44. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #16 was admitted on [DATE] and started hospice services on 01/09/25. Diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, anxiety, malnutrition, and peripheral vascular disease (PVD). Review of Resident #16's assessments revealed there was no Significant Change assessment completed within 14 days of Resident #16's hospice admission. 2. Medical record review revealed Resident #17 was admitted on [DATE] and started hospice services on 05/11/25. Diagnoses included diabetes, dementia, anxiety, major depressive disorder, gastro esophageal reflux disease (GERD), atrial fibrillation, Alzheimer's disease, sepsis, and peripheral vascular disease (PVD). Review of Resident #17's assessments revealed there was no Significant Change assessment completed within 14 days of Resident #17 hospice admission. 3. Medical record review revealed Resident #42 was admitted on [DATE] and started hospice services on 03/11/25. Diagnoses included neurocognitive disorder with Lewy bodies, depression, chronic obstructive pulmonary disease (COPD), and diabetes. Review of Resident #42's assessment revealed there was no Significant Change assessment completed within 14 days of Resident #42's hospice admission. Interview on 06/17/25 at 9:35 A.M. with MDS Nurse #105 confirmed Residents #16, #17, and #42 did not have the required Significant Change assessment completed. 366271 Page 5 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident assessments were accurate related to hospice services and use of tobacco. This affected seven residents (Residents #3, #12, #16, #17, #28, #42, and #43) of sixteen residents reviewed for Minimum Date Set (MDS) assessment accuracy. Facility census was 44. Residents Affected - Some Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and started on hospice services on 03/12/25. Diagnoses included dementia, gastro esophageal reflux disease (GERD), insomnia, anxiety, chronic pain, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] and started on hospice services on 02/04/25. Diagnoses included dementia, schizoaffective disorder, anxiety, GERD, diabetes, major depressive disorder, and tachycardia. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 3. Medical record review revealed Resident #16 was admitted on [DATE] and started hospice services on 01/09/25. Diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, anxiety, malnutrition, and peripheral vascular disease (PVD). Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 4. Medical record review revealed Resident #17 was admitted on [DATE] and started hospice services on 05/11/25. Diagnoses included diabetes, dementia, anxiety, major depressive disorder, GERD, atrial fibrillation, Alzheimer's disease, sepsis, and PVD. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 5. Medical record review revealed Resident #42 was admitted on [DATE] and started hospice services on 03/11/25. Diagnoses included neurocognitive disorder with Lewy bodies, depression, COPD, and diabetes. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 6. Medical record review revealed Resident #43 was admitted on [DATE] and started hospice services on 02/06/25. Diagnoses included Alzheimer's disease, depression, anxiety, atrial fibrillation, heart disease, dementia, and scoliosis. 366271 Page 6 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. Interview on 06/18/25 at 2:00 P.M. with MDS Nurse #105 confirmed Residents #3, #12, #16, #17, #42, and #43's MDS assessments did not include the provision of Hospice Services. Residents Affected - Some 7. Review of the medical record for Resident #28 revealed an admission date of 03/13/25. Diagnoses included chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. Review of the smoking assessment dated [DATE] revealed Resident #28 smoked and required supervision. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and did not use tobacco. Interview on 06/17/25 at 10:54 A.M. with Resident #28 revealed she smoked at the facility and had been a smoker for 50 years. Interview on 06/17/25 at 12:57 P.M. with MDS Nurse #105 revealed she was not aware Resident #28 was a smoker when she completed the MDS assessment dated [DATE] and verified the MDS for tobacco use was marked incorrectly. 366271 Page 7 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan for smoking for Resident #28. This affected one resident (#28) of one resident reviewed for smoking. The facility census was 44. Findings include: Review of the medical record for Resident #28 revealed an admission date of 03/13/25. Diagnoses included chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. Review of the smoking assessment dated [DATE] revealed Resident #28 smoked and required supervision. Review of the smoking assessment dated [DATE] revealed Resident #28 did not require supervision or any adaptive equipment for smoking. Review of Resident #28's plan of care revealed the care plan did not address smoking. Interview on 06/17/25 at 10:54 A.M. with Resident #28 revealed she smoked at the facility and had been a smoker for 50 years. Interview on 06/17/25 at 12:57 P.M. with MDS Nurse #105 revealed she was not aware Resident #28 was a smoker when she completed the MDS assessment dated [DATE] and verified a care plan for smoking was not developed. Review of the facility policy Smoking Policy-Residents, revised July 2017 revealed any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) would be noted on the care plan, and all personnel caring for the resident would be alerted to the issues. 366271 Page 8 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#40) of five residents (#5, #40, #11, #3, and #12) reviewed for unnecessary medications. The facility census was 44. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/25/23. Diagnoses included dementia, depression, Alzheimer's disease, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the pharmacy recommendation dated 03/13/25 revealed Resident #40 had a medication order for fluticasone nasal spray two spray each nostril (EN) everyday (QD) which started 11/28/23. The recommendation indicated in an effort to ensure the lowest most effective does was administered please consider discontinuing fluticasone nasal spray or change the fluticasone nasal spray to one spray EN QD as needed (prn) for rhinitis. A handwritten check was marked next to change fluticasone nasal spray to one spray EN QD prn rhinitis and was signed by the physician and dated 03/25/25. Review of the physician orders for June 2025 revealed active orders for Flonase (fluticasone propionate) Allergy Relief Nasal Suspension 50 micrograms/activation two spray in both nostrils in the morning for sinuses with a start date of 11/28/23. Interview on 06/17/25 at 5:06 P.M. with Corporate Regional Nurse #231 verified that although the pharmacy recommendation regarding fluticasone nasal spray was approved by the physician on 03/25/25 the recommendation was not implemented. 366271 Page 9 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and interview, the Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly. This had the potential to affect all 44 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility QAPI committee sign in sheets provided by the facility revealed a single sign-in sheet for May 2025. Interview on 06/17/25 at 4:18 P.M. with the Administrator verified the QAPI committee sign-in sheet dated May 2025 was the only sign in sheet available. No additional information was provided to support additional QAPI meetings were held. 366271 Page 10 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, policy review, and CMS memorandum QSO-24-08-NH review, the facility failed to provide care to Residents #7, #29, and #46 in a manner to prevent the potential spread of infection. This affected Residents #7, #29 and #46 and had the potential to affect all residents residing in the facility. The facility census was 44. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment, required extensive to total dependence for all activities of daily living, and was always incontinent of urine and bowel. Review of the care plan for Resident #7 dated 03/18/25 revealed the resident had pressure ulcers related to impaired mobility. Interventions included to administer treatments as ordered and monitor for effectiveness, and to monitor/document/report any changes in skin status appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. Review of the physician's order dated 05/18/25 revealed an order to clean Resident #7's sacrum with normal saline solution, pat dry, apply calcium alginate (antimicrobial dressing), and cover with a boarded gauze daily and as needed. Further review of physician orders revealed there was not an order enhanced barrier precautions (EBP). Observation of wound care for Resident #7 on 06/17/25 at 2:00 P.M. with Licensed Practical Nurse (LPN) #118 and the Director of Nursing (DON) revealed the DON entered Resident #7's room and applied gloves but did not wash her hands. The DON and LPN #118 began to pull down Resident #7's pants after explaining the procedure to the resident. Resident #7 became irate and began screaming she did not want the surveyor in the room and she wanted them to stop. The surveyor exited the room and LPN #118 and the DON finished care for Resident #7. Interview on 06/17/25 at 2:45 P.M. with the DON confirmed that she did not wash her hands before applying gloves and providing care to Resident #7. The DON also confirmed that Resident #7 had wounds and should be in enhanced barrier precautions due to her compromised status. Review of the facility policy enhanced barrier precautions, revised March 2024, revealed enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices regardless of colonization. Review of QSO-24008 NH with a posted date of 03/20/24 revealed EBP recommendations included use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. 2. Review of the medical record for Resident #29 revealed an admission date of 12/23/21. Diagnoses 366271 Page 11 of 12 366271 06/18/2025 The Pavilion at Canal Fulton for Nursing and Rehab 7055 High Mill Avenue NW Canal Fulton, OH 44614

F 0880 Level of Harm - Minimal harm or potential for actual harm included unspecified dementia, major depressive disorder, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 required extensive assistance to dependence for all activities of daily living. Review of the care plan dated 06/16/25 revealed Resident #29 was at risk for infection. Interventions included to monitor for signs and symptoms of infection and to administer medications as ordered. Residents Affected - Many Review of the medical record for Resident #46 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, atrial fibrillation, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment and required set-up to moderate assistance for all activities of daily living. Review of the care plan dated 06/16/25 revealed Resident #46 was at risk for infection. Interventions included to monitor for signs and symptoms of infection and to administer medications as ordered. Observation of medication administration on 06/18/25 at 8:50 A.M. with Licensed Practical Nurse (LPN) #134 revealed LPN #134 preparing medications for Resident #29 and then entering Resident #29's room to administer the medications. After administering the medications to Resident #29, LPN #134 exited the room returned to the medication cart and began preparing medications for Resident #46. LPN #134 then entered Resident #46's room and administered Resident #46's medications. LPN #134 then exited the room of Resident #46 and returned to the medication cart. No hand hygiene was performed. Interview on 06/18/25 at 9:12 A.M. with LPN #134 confirmed she did not wash her hands or use hand sanitizer after administering medications to Resident #29 and before administering medications to Resident #46. Review of the facility policy, hand hygiene, revised October 2023, revealed hand hygiene was indicated immediately before touching a resident. 366271 Page 12 of 12