Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A facility failed to provide adequate supervision when nursing staff were found sleeping during their shifts, affecting residents at high risk for elopement. Residents with dementia and schizophrenia diagnoses, requiring close supervision, were left unsupervised on the 100 and 300 halls. The incident was observed by the Administrator and RDCS during unannounced rounds, highlighting a significant lapse in resident safety.
A facility failed to provide appropriate dementia care for a resident with dementia and behavioral disturbances. The resident, identified as an elopement risk, displayed wandering behaviors. A CNA, unfamiliar to the resident, attempted to redirect the resident during sundowning, leading to agitation. To prevent altercations, the CNA blocked the resident's access to certain areas with chairs, constituting involuntary seclusion, which violated the facility's policy on abuse and neglect.
The facility failed to maintain a clean and safe environment, affecting all residents. Observations included an active ceiling leak, blocked air vents, rusted shower chairs, and missing privacy curtains. Electrical outlet covers were off or loose, and moldy food was found in the dining room fridge. Walls and furniture were stained and damaged, and wheelchairs lacked padding. Handrails were chipped, and overbed lights lacked covers.
A facility failed to ensure accurate documentation of a resident's advance directive preferences. Despite the resident's wish for a DNRCC status, records showed conflicting information, with electronic orders indicating a full code status. The resident confirmed his preference for DNRCC, and the DON acknowledged the discrepancies.
A facility failed to complete the required MDS 3.0 assessments for a resident who left against medical advice and returned the same day. The resident, with conditions including paraplegia and opioid dependence, did not have the necessary discharge and entry assessments completed, as confirmed by the MDS nurse.
The facility failed to complete timely PASRR assessments for two residents with mental disorders or intellectual disabilities. One resident was readmitted without a PASRR assessment after leaving against medical advice, while another remained beyond a 30-day exemption period without a full assessment. These lapses were confirmed by facility staff.
A facility failed to update a resident's care plan to address wandering behaviors and potential elopement risk. The resident, with schizophrenia and cognitive delay, was identified as high risk for elopement but lacked a care plan for these issues. An incident occurred where the resident wandered off during a smoke break, leading to the implementation of a wanderguard and frequent checks, which were not reflected in the care plan.
The facility did not implement pharmacy recommendations for two residents, affecting medication management. A resident's Hydroxyzine dose was not reduced, and necessary blood tests and medication timing adjustments were not made. Another resident's Diphenhydramine was not discontinued despite agreement. The DON confirmed these lapses.
A resident with a history of antiphospholipid syndrome and lupus received Warfarin without proper monitoring of INR levels, leading to a significant medication error. The facility failed to report elevated INR results in a timely manner, resulting in continued Warfarin administration despite the risk of excessive anticoagulation. The resident expressed concerns about the lack of communication regarding her INR levels, and the DON confirmed that Warfarin should have been held until INR values normalized.
The facility failed to properly store Methadone, a Schedule 2 medication, for two residents. Observations revealed that the Methadone was kept in black boxes inside medication carts that were not permanently affixed or separately locked. In one case, the box was not fully closed, allowing access without unlocking. The facility's medication storage policy lacked specific guidelines for storing controlled medications.
The facility failed to maintain accurate and complete medical records for two residents regarding laboratory findings. One resident, with dementia and schizophrenia, lacked recorded Depakote lab results after a specific date, while another resident, with cognitive deficits and hypertension, was missing Valproic Acid lab results. An LPN confirmed these omissions and retrieved the missing results from the lab website.
The facility failed to maintain a safe and clean environment, with issues such as dirty and worn carpets, chipped paint, and cracked showers observed in various areas. A broken window in the common area and unpainted wall patches were also noted. The Administrator confirmed these findings, and the resident complaint log indicated multiple housekeeping issues.
A resident with a traumatic brain injury and hemiplegia was found smoking in their room, against the facility's policy allowing smoking only in designated outdoor areas. Despite having intact cognition, the resident was non-receptive to re-education and continued to smoke indoors. Observations showed cigarette butts and a lighter on the windowsill, with the window partially open and the screen torn. The care plan noted behavior issues but lacked interventions to address them.
The facility failed to provide sufficient dietary staff, affecting meal service for all 49 residents. Staffing inconsistencies and a lack of pay incentives led to nurse aides filling in without proper protocols, causing meal delays. The Dietary Manager's absence was not covered, resulting in a cook working double shifts.
The facility's kitchen was found to be unsanitary, with debris and grime on the floor, improperly stored food items, and ice buildup in the freezer. Observations included undated and unsealed food items, food debris under cooler shelving, and a bug in the dry storage area. The Regional Culinary Director confirmed these issues, which violated the facility's food storage policy.
The facility failed to maintain its commercial laundry machines, affecting all 49 residents. The large Unimac machine lost power due to wiring issues, and the small machine was out of service until repaired. Without a backup, the maintenance supervisor transported laundry to a sister facility. Staff noted delays in returning residents' clothing, and the Administrator was unaware of the small machine's repair needs. A review indicated the slab under the large machine was unstable, prompting a replacement recommendation.
The facility failed to maintain an adequate supply of clean towels and washcloths, affecting 31 residents. Observations revealed empty linen rooms, and staff confirmed the shortage, impacting resident care, including missed shower days. Budget constraints and lack of established par levels contributed to the deficiency.
A resident and their POA were denied access to personal records, including government-issued documents, despite a signed release request. The facility lacked a procedure for handling resident information, leading to misplacement of documents and an open misappropriation case. The resident had intact cognition and requested the documents prior to discharge, but the administrator did not comply.
The facility failed to maintain kitchen cleanliness and proper food storage. Observations revealed grease buildup on the oven hood suppression system and improperly stored food items in the walk-in refrigerator and freezer, including undated and uncovered items. These findings were confirmed by a cook during the tour.
The facility failed to maintain the laundry area in a clean, safe, and sanitary condition, with lint-covered areas behind washers, a poorly maintained dryer ventilation system, and significantly water-stained ceiling tiles. These issues were confirmed by the Laundry Director.
The facility failed to conduct annual performance reviews for STNAs as required, affecting one of two personnel files reviewed and potentially impacting all 43 residents. This was confirmed during an interview with the HRD.
Inadequate Supervision Due to Sleeping Staff
Penalty
Summary
The facility failed to provide appropriate supervision to residents, as nursing staff were found sleeping during their shifts. This incident affected three residents identified as high risk for elopement, residing on the 100 and 300 halls, and had the potential to affect all residents on these halls. The residents involved had various diagnoses, including dementia, schizophrenia, and cognitive impairments, which increased their risk of elopement and required close supervision. Resident #44, residing on the 300-hall, had a history of attempts to leave the facility unattended and was identified as an elopement risk. The resident had a wanderguard device to alert staff if an exit was attempted. Similarly, Resident #8, residing on the 100-hall, was also at high risk for elopement due to being ambulatory and disoriented. Both residents required interventions such as reorientation and supervision to prevent wandering and potential elopement. On the night of the incident, CNAs assigned to the 100 and 300 halls were found sleeping, leaving the residents unsupervised. The facility's Administrator and Regional Director of Clinical Services observed the sleeping staff during unannounced rounds. This lack of supervision posed a significant risk to the residents, particularly those identified as high risk for elopement, as they were left without the necessary oversight to ensure their safety.
Inappropriate Dementia Care and Involuntary Seclusion
Penalty
Summary
The facility failed to provide appropriate dementia care for a resident diagnosed with dementia with behavioral disturbance, anxiety disorder, cognitive communication deficit, and schizophrenia. The resident, who was identified as an elopement risk and wanderer, displayed wandering behaviors and had a history of attempting to leave the facility unattended. The care plan for the resident included interventions such as offering pleasant diversions and structured activities to distract from wandering, but these measures were not effectively implemented. An incident occurred where a Certified Nurse Aide (CNA) was assigned to care for the resident, despite being new and unfamiliar to the resident. During the evening, the resident began to exhibit sundowning behaviors, including disrobing and attempting to enter other residents' rooms. The CNA and a Registered Nurse (RN) attempted to redirect the resident using calm voices and physical guidance, but the resident became agitated and attempted to hit the staff. In an effort to prevent altercations with other residents, the CNA placed chairs to block the resident's access to certain areas, which was later identified as involuntary seclusion. The facility's policy on abuse, neglect, and exploitation prohibits involuntary seclusion, which is defined as confining a resident against their will. The Regional Director of Operations confirmed that the CNA's actions of obstructing an area with chairs constituted involuntary seclusion. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policies and procedures for dementia care.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained environment, which had the potential to affect all 43 residents. During an environmental tour, several deficiencies were observed, including an active ceiling leak in the first-floor common area, noticeable scratches on the floor in a resident's room, and a blocked air vent covered with industrial tape. Additionally, a shower chair was found to be significantly rusted, and some rooms lacked privacy curtains. Electrical outlet covers were either off or loose, and cobwebs were present on a ceiling. A shower head was observed to leak water continuously, and the dining room walls were stained and scuffed. Moldy food was found in the common use fridge, and tables were in poor condition, with one held together by duct tape. Further observations included torn non-skid strips, stained blankets and bed sheets, and crumbling wall areas around heating/AC units. A geriatric chair contained food crumbs, and a room had numerous brown dots of an unknown substance. Wallpaper was falling off in several rooms, and a patched wall was not properly finished. Wheelchairs lacked padding, and a large red stain was noted on a floor. Handrails throughout the facility were chipped and scratched, and overbed lights lacked covers. Several rooms had extremely scuffed and scratched walls, and bathroom walls were also in poor condition.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive orders and information were accurately documented throughout the medical record. This deficiency was identified during a review of the records for a resident who was admitted with diagnoses including alcohol dependence, schizoaffective disorder, bipolar disorder, and cocaine abuse. The resident was cognitively intact and receiving hospice services. Despite the resident's expressed desire to have a DNRCC (do not resuscitate comfort care) status, inconsistencies were found in the medical records. The electronic physician's orders and care plan indicated a full code status, while the hard medical chart contained conflicting information, including a signed DNRCC form. Interviews with the resident confirmed his wish to maintain the DNRCC status, and the Director of Nursing verified the discrepancies in the resident's code status documentation. The facility's policy on advanced directives requires that the plan of care be consistent with the resident's documented treatment preferences. However, the failure to ensure accurate and consistent documentation of the resident's advance directive preferences throughout the medical record led to this deficiency.
Failure to Complete MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) 3.0 assessment as required when a resident self-initiated discharge from the facility. This deficiency affected one resident who was admitted with diagnoses including paraplegia, bipolar disorder, opioid dependence, and drug-induced constipation. The resident left the facility against medical advice and was administered methadone prior to departure. The resident later returned to the facility from a local hospital via ambulance on the same day. Upon review, it was found that the required discharge return not anticipated assessment and the subsequent entry assessment were not completed for the resident. An interview with the MDS nurse confirmed that these assessments were not conducted as required. The facility's policy and the Resident Assessment Instrument (RAI) manual specify that an OBRA Discharge assessment should be completed for unplanned discharges, such as when a resident leaves against medical advice, but this was not adhered to in this case.
Failure to Complete Timely PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure a valid Pre Admission Screen and Resident Review (PASRR) was completed timely for two residents, affecting their compliance with federal requirements. Resident #14, who was admitted with diagnoses including paraplegia, bipolar disorder, opioid dependence, and drug-induced constipation, did not have a PASRR assessment completed upon readmission to the facility after leaving against medical advice. This oversight was confirmed by the MDS Nurse, indicating a lapse in the required assessment process for residents with mental disorders or intellectual disabilities. Similarly, Resident #27, admitted with bipolar disorder, anxiety disorder, and opioid dependence, was initially exempt from PASRR requirements due to a hospital exemption for a stay of less than 30 days. However, the resident remained in the facility beyond the 30-day exemption period without a full PASRR assessment being conducted. This was verified by the Social Service Designee, highlighting a failure to adhere to the necessary assessment timeline for residents requiring extended care.
Failure to Update Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to update the care plan for Resident #148 to address her wandering behaviors and potential for elopement. Resident #148, who was admitted with schizophrenia and cognitive delay, was identified as being at high risk for elopement due to her ambulatory status and mental health condition. Despite this, her care plan did not include measures for wandering or elopement prevention. This oversight was noted during a review of her medical records and care plan. An incident occurred where Resident #148 wandered off the patio during a supervised smoke break, necessitating staff intervention to redirect her back inside. Following this event, a wanderguard was placed on her ankle, and staff were instructed to check on her every 15 minutes. However, these measures were not reflected in her care plan. The Regional Director of Clinical Services confirmed the absence of a care plan addressing these risks, highlighting a deficiency in the facility's care planning process for this resident.
Failure to Implement Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to act on pharmacy recommendations for two residents, leading to deficiencies in medication management. For Resident #36, the pharmacy recommended a dose reduction of Hydroxyzine, blood level monitoring for magnesium and thyroid hormones, and a change in administration times for Levothyroxine and magnesium to prevent absorption interference. Despite these recommendations being agreed upon and signed by the nurse practitioner or physician, there was no evidence that the necessary actions were taken, such as ordering or drawing the recommended blood levels, reducing the Hydroxyzine dose, or adjusting the medication administration times. Similarly, for Resident #11, the pharmacy recommended discontinuing Diphenhydramine, which was agreed upon by the nurse practitioner. However, the medication was not discontinued as recommended. The Director of Nursing confirmed these findings during interviews, indicating a lapse in following through with accepted pharmacy recommendations, affecting the quality of care provided to the residents.
Failure to Monitor INR Levels Before Warfarin Administration
Penalty
Summary
The facility failed to appropriately monitor and report relevant lab values before administering Warfarin to a resident, leading to a significant medication error. The resident, who had a history of antiphospholipid syndrome, systemic lupus, and venous thrombosis, was on a regimen that required regular INR lab draws to monitor Warfarin effectiveness. Despite an active order for INR lab draws every Monday, Wednesday, and Friday, and the requirement to report these results to the medical provider, the INR result from 01/03/25 was not communicated to the practitioner until 01/05/25. During this period, the resident continued to receive Warfarin, even though the INR value was above the therapeutic range, indicating a risk of excessive anticoagulation. The resident expressed concern about the lack of communication regarding her INR levels and the continued administration of Warfarin despite elevated INR values. The Assistant Director of Nursing, who administered the Warfarin on 01/03/25, assumed the INR was within acceptable limits due to a lack of reported concerns from the previous shift. The Director of Nursing confirmed that Warfarin should have been held from 01/03/25 until the INR returned to normal limits. This oversight placed the resident at risk for complications associated with excessive anticoagulation.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored in a separately locked and permanently affixed compartment, affecting two residents who were prescribed Methadone, a Schedule 2 medication with a high potential for abuse. During an observation of medication administration for one resident, it was noted that the Methadone was stored in a black box inside the medication cart that was not permanently affixed or separately locked. The box's lid, which was supposed to lock automatically, was not fully closed, allowing the nurse to remove the Methadone without unlocking it. This was confirmed by an LPN present at the time. In another instance, the Methadone for a second resident was observed to be stored in a similar locked black box that was also not permanently affixed to the cart. This finding was confirmed by another LPN. The facility's medication storage policy, dated 2001, did not specify how controlled medications should be stored, contributing to the deficiency.
Inaccurate and Incomplete Medical Records for Laboratory Findings
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding laboratory findings. Resident #11, who was admitted with diagnoses of dementia, schizophrenia, and insomnia, had a physician order for a Depakote laboratory test dated 09/26/24. However, upon review, there were no laboratory results recorded in the resident's medical record after 07/11/24. This discrepancy was confirmed during an interview with an LPN, who subsequently accessed the laboratory website to retrieve and print the missing results for the resident's medical record. Similarly, Resident #24, admitted with diagnoses including cognitive communication deficit, dementia, and hypertension, had a physician's order for Valproic Acid laboratory testing every three months. The review of the resident's medical record revealed an absence of laboratory results after 07/09/24. This was verified by the same LPN, who then logged onto the laboratory company's website to print the missing results, which should have been included in the resident's paper chart. These omissions in maintaining up-to-date laboratory results in the residents' medical records highlight a deficiency in the facility's record-keeping practices.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations during a tour with the Administrator. The elevator, a primary means of transport for residents, had a dirty and worn carpet. The 100 wing had a buildup of dirt along the baseboards, and several resident rooms had issues such as chipped paint, dirt and debris buildup, and dust accumulation. Specific rooms had additional problems, such as cracked showers, bubbled carpets posing trip hazards, and rusted door jams with peeling paint. These deficiencies were confirmed by the Administrator during the observations. Further issues were noted, including a broken window in the common area covered with plywood, which had not been repaired for a week. The 100 hall had multiple unpainted wall patches. The resident Concern/Complaint log revealed multiple complaints about housekeeping and room cleanliness. The facility's policy on maintaining a homelike environment emphasized cleanliness and order, which was not upheld. These deficiencies were identified during the investigation of several complaint numbers.
Inadequate Supervision and Unsafe Smoking Practices
Penalty
Summary
The facility failed to ensure adequate supervision and safe maintenance of smoking materials for a resident identified as a smoker. The resident, who had a traumatic brain injury and hemiplegia, was found to have been smoking in their room, contrary to the facility's smoking policy which permits smoking only in designated outdoor areas. Despite having intact cognition and requiring only setup assistance for personal hygiene, the resident was non-receptive to re-education on the smoking policy and continued to smoke in their room. Observations revealed that the resident had a small plate used as an ashtray with cigarette butts and a lighter on the windowsill, with the window partially open and the screen torn. The resident admitted to smoking in the room and refused to turn in cigarettes, despite being previously caught and educated on the policy. The care plan for the resident noted behavior problems related to hiding cigarettes and smoking in the room but lacked interventions to address these behaviors. This deficiency was identified during a complaint investigation.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of food and nutrition services, potentially affecting all 49 residents receiving meals from the kitchen. The facility's assessment indicated that food and nutrition services were overseen by a full-time dietary manager and a contracted dietitian, with a staffing plan that included one full-time dietary manager, a part-time dietitian, five full-time food service workers, and three part-time food service workers. However, the dietary services schedule revealed inconsistencies in staffing, with fewer part-time employees scheduled than planned. Interviews with residents indicated delays in meal service, with breakfast being served late on some days. Further interviews revealed that dietary staff did not stay over to the next shift due to a lack of pay incentives, leading to nurse aides working in the kitchen without adhering to all food production protocols. The Regional Culinary Director confirmed that nurse aides filled in when the dietary department was short-staffed. Additionally, the Dietary Manager was off for six weeks due to surgery, and the facility did not adjust the schedule to cover her absence, resulting in a cook working double shifts. The facility's policy stated that adequate staffing should be provided to meet the needs of the resident population, but this was not adhered to, leading to the identified deficiency.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect all 49 residents receiving meals. During an initial kitchen tour, several issues were observed, including debris and grime on the kitchen floor, and improperly stored food items in the dry food storage area. Specific concerns included opened and undated bread, confection sugar not sealed or dated, and a box of sugar stored in an open cardboard box with a scoop inside. Additionally, chicken gravy packets were undated, and a 50-pound bag of long grain rice was unsealed with a scoop stored inside. The dry food storage floor also had dried onion peel debris with a bug crawling through it. Further observations revealed food debris under the shelving in the dairy walk-in cooler and a thin layer of ice buildup on the freezer floor, with a large buildup of ice on the ceiling. Undated open plastic bags of country fried steak and hush puppies were also found in the freezer. The Regional Culinary Director confirmed these areas of concern at the time of observation. The facility's policy on food storage, which was undated, stated that food should be stored and prepared according to professional standards to prevent contamination, using metal or plastic containers with tight-fitting covers for bulk foods, and all containers must be accurately labeled.
Facility Fails to Maintain Safe Laundry Equipment
Penalty
Summary
The facility failed to maintain its commercial laundry machines in safe operating condition, affecting all 49 residents. On June 13, 2024, the large Unimac commercial laundry machine lost power and stopped working due to wiring issues, as advised by a repair technician. The small Unimac commercial washing machine was also out of service until June 14, 2024, when it was repaired. However, the facility had no backup commercial laundry machine available, leading to the maintenance supervisor transporting soiled laundry to a sister facility for cleaning. The Director of Maintenance confirmed that the small machine had been out of use since January 2024 due to a missing part, and the large machine was not in use following the technician's advice. Interviews with staff revealed that the Director of Nursing noted delays in returning residents' clothing due to the broken washing machine. The Administrator was unaware of the small machine's repair needs at the time. A review of the facility's sales and security agreement indicated that the slab under the large machine was moving and had come free, prompting a recommendation to replace the machine. The facility's maintenance policy, dated December 2009, stated that maintenance service would be provided to all areas of the building, grounds, and equipment. This deficiency was investigated under Complaint Number OH00154970.
Inadequate Linen Supply Affects Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean towels and washcloths for resident care, affecting 31 out of 49 residents. During an environmental tour, it was observed that the clean linen rooms on units 200 and 300 were inadequately stocked, with unit 200 having no clean towels or washcloths and unit 300 having only a few available. Interviews with staff, including a Regional Director, State Tested Nurse Assistants, and a Registered Nurse, confirmed the shortage of linens, which impacted resident care, including missed shower days. A resident reported feeling terrible about missing a shower due to the lack of available towels. The Laundry Aid mentioned that budget constraints limited the ordering of necessary linens, and the Central Supply Supervisor noted that supplies were ordered only as needed without established par levels. The Housekeeping Supervisor stated that linen par levels should be double the resident census, but orders required corporate approval. The facility's policy emphasized providing a safe, clean, and homelike environment, which includes maintaining adequate linen supplies, but this was not adhered to, leading to the identified deficiency.
Failure to Provide Resident Access to Personal Records
Penalty
Summary
The facility failed to ensure that a resident and their legal representative had access to personal records upon request, affecting one resident out of four reviewed for resident rights. The resident, who had intact cognition, was admitted with multiple medical diagnoses and had appointed a family member as their Power of Attorney (POA). Despite a signed request for the release of health information, the facility did not provide the resident's personal documents, including a birth certificate, social security card, state identification card, and military discharge papers, which were reportedly held in the former social worker's office. The resident and their POA requested these documents prior to discharge, but the facility's administrator refused to provide them. Interviews revealed that the facility lacked a standard procedure for receiving and storing resident information, leading to the misplacement of important documents. The Ombudsman reported an open misappropriation case against the facility due to the missing documents and poor communication with the resident's family member. The former social worker confirmed that the documents were to be returned upon request, but the administrator did not comply. The facility's policy stated that resident records should be safeguarded and released upon a written request, which was not honored in this case.
Failure to Maintain Kitchen Cleanliness and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not ensure that foods were stored to prevent contamination and spoilage. During a tour of the kitchen, it was observed that the oven hood suppression system was coated in a layer of brown and black grease, and the grease collection area was coated in thick, chunky grease. In the walk-in refrigerator, several food items were found to be improperly stored: lettuce was significantly brown and past its best buy date, a bag of carrots was opened and past its best buy date, a bag of pepperoni was open and undated, and various other food items were undated and uncovered. In the walk-in freezer, a bag of omelettes and a bag of cream puffs were open and undated. These findings were confirmed by a cook during the tour. The facility's policy on food storage, which was undated, stated that food should be stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination.
Laundry Area Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the laundry area in a clean, safe, and sanitary condition, potentially affecting all 43 residents. Observations revealed that the area behind two industrial-sized washers was covered in lint, and the power cords were encased in lint debris. Additionally, a household-sized dryer had a ventilation system held together with dry wall spackle. The ceiling tiles in the laundry room were significantly water-stained, with one tile above the clean linen area being brown in color and sagging down multiple inches. These findings were confirmed by the Laundry Director during the observation.
Failure to Conduct Annual Performance Reviews for STNAs
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) received a performance review at least every 12 months as required. This deficiency was identified during a review of personnel files and staff interviews. Specifically, the personnel file for STNA #201, who was hired on 07/01/22, lacked evidence of a performance review completed every 12 months. This issue was confirmed during an interview with the Human Resource Director (HRD) on 05/13/24. The deficiency had the potential to affect all 43 residents residing in the facility, as it was found in one of two STNA personnel files reviewed that were employed for more than one year at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Royalton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenue At Broadview Heights | 2.7 mi | ★★★★★ | 14 | 0 |
| North Royalton Post Acute | 2.7 mi | ★★★★★ | 6 | 0 |
| Diplomat Healthcare | 3.2 mi | ★★★★★ | 8 | 0 |
| Pleasantview Care Center | 3.6 mi | ★★★★★ | 1 | 0 |
| Pleasant Lake Villa | 3.7 mi | ★★★★★ | 0 | 0 |
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