Health inspection·January 8, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few especially around the bottom edges of the floor and on the cord for the emergency call light. The air conditioning unit next to Resident #81's bed had silver tape around the edges of the unit against the wall. There were some gaps observed in the tape. (Photographic evidence obtained) During an interview on 1/07/2026 at 3:05 PM the Maintenance Director stated that there had been a leak from the sink behind the wall in [Resident #81 name's room], under the sink. It just needed to be sanded and painted. In the bathroom, we need to re-do the wall where there had been a leak behind the toilet. Review of the rounding log from 1/17/2025 documented maintenance issues identified for Resident #81's room. The comments/follow-up for the room read, Paint under sink, and Door frame. Review of the policy and procedure titled, Maintenance Service, last reviewed on 1/22/2025 read, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards. d. maintaining the heat/cooling system and emergency generator in good working order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 2 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 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 interview and record review, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for 3 of 9 residents, Residents #2, #9, and #35. Findings include: Residents Affected - Few Review of the facility policy and procedure titled Resident MDS [Minimum Data Set] Assessment and Care Planning Policy with a last review date of 1/22/2025 read, Purpose: To provide interdisciplinary observation and assessment to ensure the most accurate assessment of resident functional capacity. Review of Resident #9 Minimum Data Set titled, Quarterly dated 10/21/2025 documented in Section I Diagnosis did not include psychotic disorder or delusion disorder. Review of Resident #9's admission record documented the resident was admitted to the facility on [DATE] with diagnosis to include delusional disorders (onset on 5/18/2023) and psychotic disorder with delusions (onset on 2/1/2024). Review of Resident #9's [Name of mental health provider] note dated 12/18/2025 read, History of Present Illness: Patient was admitted on [DATE] due to hyperlipidemia, unspecified. Allergic to ACE [Angiotensin-Converting Enzyme] inhibitors. She has a Psych HX [History] of dementia, depression, delusional disorders, psychotic disorder and a medical HX of cognitive communication deficit, muscle weakness, HTN [hypertension]. During an interview on 1/8/2026 at 10:03 AM the MDS Coordinator stated, It will have to be modified [Resident #9's name] MDS since she does have a diagnosis of psychotic disorder and delusional disorders. Review of Resident #2's MDS Assessment, a quarterly assessment, dated 11/05/2025 documented the resident has a BIMS (Brief Interview for Mental Status) Score of 15 out of 15, meaning she was cognitively intact. The special treatments and programs she was utilizing were oxygen therapy and tracheostomy care. There was a no, documented for suctioning. Review of Resident #2's Census data revealed she was initially admitted to the facility on [DATE] with medical diagnoses to include chronic obstructive pulmonary disease, unspecified; heart failure, unspecified; Type 2 diabetes mellitus without complications; anxiety disorder, unspecified; tracheostomy status; dependence on supplemental oxygen; paroxysmal atrial fibrillation Review of Resident #2's Care Plan documented a focus of, [Resident #2's name] has a tracheostomy and she does her own trach care including suctioning. [Resident #2's name] administers her own nebulizer treatments. [Resident #2's name] has continuous oxygen. Date Initiated: 09/03/2025 Revision on: 01/06/2026 Review of Resident #2's physician orders dated 1/02/2026 read, Resident may do self Trach/care and Neb treatment R/T [related to] demonstrate proper techniques. All Trach-care or orders for trach, oxygen and suction. During an interview on 1/07/2026 at 11:05 AM the MDS RN (Registered Nurse) stated, I don't know why [Resident #2's name] had no marked for suctioning. She [MDS staff] knew that the resident had a tracheostomy and used suctioning. It did not make sense that she would have made that faux pas [a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 3 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few French term meaning a blunder]. She [MDS staff] utilized the RAI [Resident Assessment Instrument] to guide the MDS assessments. She [MDS staff] was responsible for the section regarding special treatment such as suctioning. Review of Resident #35's admission Data documented she was admitted on [DATE] with medical diagnoses to include nondisplaced fracture of lateral condyle of left tibia, subsequent encounter for closed fracture with routine healing; generalized anxiety disorder; type 2 diabetes mellitus without complications; acute kidney failure with tubular necrosis; end stage renal disease. Review of Resident #35's MDS Assessment, a Significant Change, dated 12/24/2025 documented that she had a BIMS score of 15 out of 15, meaning she was cognitively intact; that she had limitations in range of motion on both sides of her lower extremities (her legs), was dependent of others for her mobility an all of her care except needing only set-up/clean-up assistance for eating. She was always incontinent of urine and frequently incontinent of bowels. In the section focused on documenting a resident's health issues, aiming to capture a holistic view of their well-being, she was assessed as not having a condition or chronic disease that may result in a life expectancy of less than 6 months [to live]. For special treatments or programs, it was documented that she was receiving hospice care. Review of Resident #35's Care Plan documented, Focus: [Resident #35's name] is on hospice care with [name of local] Hospice. Dx: [diagnosis] Acute Kidney Injury. Initiated: 12/18/2025; Revision on: 12/18/2025. Focus: [Resident #35's name] has renal insufficiency r/t [related to] ESRD [end stage renal disease] She does not wish to have dialysis. Date initiated: 12/29/2025; Revision on: 12/29/2025. Review of Resident #35's physician orders documented dated 12/19/2025 read, Admit to [name of local hospice company] Hospice r/t acute kidney injury. Review of the binder titled, [name of local hospice] documented Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care dated 12/12/2025 and a Hospice Certification and Plan of Care dated 12/12/2025. The diagnosis documented for admission to hospice and certification of terminal illness was acute kidney failure with tubular necrosis. Resident #35's imminence of death was documented as < (less than) 6 months. During an interview on 1/07/2026 at 4:10 PM the DON (Director of Nursing) stated the prognosis or imminence of death for a resident admitted to hospice was usually 6 months or less. She was not aware that Resident #35's recent MDS (Minimum Data Set) Assessment did not document her prognosis as 6 months. The expectation was that the MDS [nurse] would review the documentation and correctly enter the information in the MDS assessment. During an interview on 1/07/2026 at 4:20 PM the MDS RN stated that she had completed an MDS Assessment for a significant change for Resident #35 recently because she was admitted to hospice. She did not mark question J1400, regarding a prognosis of less than 6 months of life expectancy as 'yes,' because she did not see any documentation stating that prognosis. She was aware that for a resident to be admitted to hospice they had to have a terminal diagnosis and a life expectancy of six months or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 4 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 Preadmission Screening and Resident Review (PASRR) was accurately completed for 3 of 8 residents, Residents #8, #11 and #26, reviewed for behavioral management.Findings include: Review of Resident #26's admission record documented the resident was admitted on [DATE] with diagnoses to include major depressive disorder (onset date: 8/8/2025).Review of Resident #26's PASSR dated 8/18/2025 did not show depressive disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #26's quarterly Minimum Data Set assessment dated [DATE] documented Depression under Section I- Active Diagnoses.Review of Resident #26's [Name mental health provider] note dated 12/4/2025 read, History of Present Illness: Past psych history includes MDD [Major Depressive Disorder].Review of Resident #8's admission record documented the resident was admitted on [DATE] with diagnoses to include anxiety disorder (onset date: 1/29/2025) and depression (onset 1/29/2025).Review of Resident #8's PASSR dated 11/29/2025 did not show depressive disorder or anxiety disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] documented Depression and Anxiety under Section I- Active Diagnoses.Review of Resident #8 [Name of mental health provider] note dated 12/18/2025 read, History of Present Illness: Past psych history includes insomnia not due to substance or known physiological condition, GAD [generalized anxiety disorder], dementia in other disease classified elsewhere, mild, with psychotic disturbance, MDD.Review of Resident #11's admission record documented the resident was admitted on [DATE] with diagnoses to include anxiety disorder (onset date 8/27/2025) and autistic disorder (onset date 8/27/2025).Review of Resident #11's PASSR dated 8/29/2025 did not show autistic disorder or anxiety disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making.Review of Resident #11's quarterly Minimum Data Set assessment dated [DATE] documented Autistic and Anxiety under Section I- Active Diagnoses.Review of Resident #11 [Name of mental health provider] note dated 12/4/2025 read, History of Present Illness: Past psych history includes anxiety, insomnia, autistic.During an interview on 1/7/2026 at 10:16 AM the Social Service Director stated, I oversee PASARR in the facility. When residents come in if they have no PASARR, I will go ahead and reach out to Keppra and request one and make sure they have one on file. When they come in from the hospital with a PASARR already completed I review the form to make sure it has the facility's name. I was not comparing to see if all the diagnosis they have listed are marked on the form.Review of the policy and procedure titled Resident Assessment-Coordination with PASARR Program with a last review date of 1/22/2025 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 5 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and record review, the facility failed to develop a care plan for 1 of 4 residents, Resident #11, reviewed for respiratory services and 1 of 8 residents, Resident #10, reviewed for behavioral management. Findings include: Review of Resident #11's physician order dated 9/24/2025 read, Oxygen 2L [liters] received via nasal cannula, may titrate to maintain SPO2 > 90% [peripheral capillary oxygen saturation greater than 90 percent] every shift for low oxygen saturation <90% [less than 90 percent]. Review of Resident #11 physician order dated 1/2/2026 read, Oxygen 2L received via nasal cannula, may titrate to maintain SPO2 > 90% every shift for low oxygen saturation < 90%. Review of Resident #11 care plan did not include oxygen as a focus. During an interview on 1/7/2026 at 11:53 AM the Minimum Data Set (MDS) Coordinator stated [Resident #11's name] care plan did not include oxygen as a focus or intervention, and it would need to be updated. Review of Resident #10's admission record documented the resident was admitted on [DATE] and diagnosis to include post-traumatic stress disorder (onset date 7/11/2023). Review of Resident #10's [Name of mental health provider] dated 12/18/2025 read, History of Present illness: Psychiatric history includes anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). During an interview on 1/7/2026 at 10:08 AM the MDS Coordinator stated, I do not see a diagnosis of PTSD mention in the care plan. A focus will need to be added. Review of the policy and procedure titled Resident MDS Assessment and Care Planning Policy with a last review dated of 1/22/2025 read, CAA triggers are used as a basis for care planning. Additional areas care planned as determined by IDT [Intradisciplinary Team], additional assessment, diagnoses, facility policy or other concerns specific to resident. Event ID: Facility ID: 105808 If continuation sheet Page 6 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to administered medication appropriately, crushing extended-release medication for 1 of 5 medication observations [Resident #1].Findings include:During an observation on 1/8/2026 at 8:11 Staff E, Unit Manager/Licensed Practical Nurse (LPN) prepared Resident #1's medications for administration. One of the medications was Potassium Chloride Extended Release. Staff E crushed all of Resident #1's medications and administered the medications to Resident #1. Review of Resident #1 physician order dated 1/2/2026 read, Klor-Con 10 Oral Tablet Extended Release 10 MEQ [milliequivalent] (Potassium Chloride) give 1 tablet by mouth one time a day for hypokalemia.During an interview on 1/8/2026 at 9:45 AM the Director of Nursing stated, Extended-release medication should not be crushed. The nurse should call the provider and have the medication changed to a liquid or a type of medication can be crushed.During an interview on 1/8/2026 at 10:50 AM with Staff E, Unit Manager/License Practical Nurse stated, Extended-Release medication cannot be crushed. I have already contacted the provider and the family to notify them of what happened and get a change of medication.During an interview on 1/8/2026 at 1:32 PM the Advance Practical Registered Nurse #1 stated, Extended-Release medication should not be crushed. It was a onetime thing, [Resident #1's name] is okay. I have no messages from nursing staff [Resident #1's name] has had any health concerns.Review of the facility policy and procedure titled Administering Medications with a last review date 1/22/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 7. If a dosage is believed to be inappropriate or excessive for a resident or is suspected if being associated with adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 7 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post the current nurse staffing information to include the facility name, the current date, the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift, and the resident census.Findings include:During an observation on 1/05/2026 at 9:35 AM the plastic document holder for the posting of the daily staffing, which was hanging on the wall in the main hallway, across from the elevator was empty/contained no documents.During an interview on 1/5/2026 at 9:40 AM the Receptionist stated [name of the HR/Staffing Coordinator] was responsible for the staffing and she had no idea where it was supposed to be posted.During an interview on 1/5/2025 at 9:50 AM the Administrator stated the staffing was to be posted in the main hallway near the nurses' station on the 100 hall.During an observation on 1/5/2025 at 9:53 AM the staffing sheet posted in the hallway on the first floor (the 100 hall), across from the nurses' station, was dated Tuesday, August 12, 2025. (Photographic evidence obtained)During an interview on 1/05/2026 at 10:03 AM the Administrator stated the expectation was that the current staffing sheet was to be posted daily.During an interview on 1/05/2026 at 10:04 AM the DON stated the expectation is that the staffing is supposed to be posted by 9:00 AM daily. It was to be posted near the lobby, across from the elevator.During an interview on 1/08/2026 at 10:25 AM the HR [Human Resources]/Staffing Coordinator stated that she posts the staffing sheet in the morning following the morning meeting, which was usually after 9:30 [AM]. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 8 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview, the facility failed to ensure the physician(s) wrote a reason for disagreement with the Resident Pharmacist Recommendations for 5 of 5 residents, Residents #2, #6, #8, #10, and #26. Findings include: Review of Resident #6's Pharmacist Recommendation dated 9/22/25 read, recommended spacing dosing of hydrocodone and valium. The physician checked disagreed and continued both medications, no reason for the decision was documented. Review of Resident #6's Pharmacist Recommendations dated 6/30/25 and 8/9/25 read, This resident is currently taking Diazepam 10 mg [milligrams] HS [hour of sleep] for anxiety. Literature indicates the maximum recommended dose for geriatric residents is 5mg/daily. Please consider re-evaluating current treatment to determine if medication is at lowest effective dose. The physician checked disagreed and continued both medications, no reason for the decision was documented. Review of the Interim Medication Regimen Review for Resident #2, dated 7/31/2025 read, Please assess risk vs. (versus) benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions &ndash; Eliquis (a blood thinner) + (plus) Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option selected by the physician was, Disagree. In the section, Physician Summary: Please indicate that the appropriate action was taken on all the aforementioned recommendations, there was nothing documented. It was signed by Physician #1 and dated 8/01/2025. Review of the Interim Medication Regimen for Resident #2 dated 9/02/2025 read, Consultant Pharmacist Recommendation to Physician: Per state and federal regulations, suggest that there is an diagnosis/indication listed on the POFs/MARs (Medication Administration Record) for each of the medications prescribed: Aripiprazole (antipsychotic): current diagnosis may not be approved at time of survey; suggest the following FDA approved dx for this medication: bipolar, mania, schizophrenia, depression associated with bipolar d/o (disorder) major depressive disorder. The option checked was disagree. Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro (an antidepressant medication): consider therapy modification. QT (refers to the QT interval, a crucial measurement on an electrocardiogram), indicating electrical recovery between beats -prolonging Agents may enhance the QTc-prolonging effect (increasing the risk of a dangerous, chaotic heart rhythm, which can cause fainting, seizures, and sudden cardiac death) of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (an irregular heartbeat). The option checked was, Disagree, and Please assess risk vs. benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions - Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option checked was, Disagree. It was signed by Physician #1 and dated 9/05/2025. There was no reason documented by the physician/provider. Review of the Interim Medication Regimen for Resident #2 dated 10/01/2025 read, Consultant Pharmacist Recommendation to Physician: The following medication are best administered within these (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 9 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some guidelines: Fluticasone-Salmeterol: rinse mouth with water after use, do not swallow, the option checked was, Disagree, and Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro: Per Lexicomp: consider therapy modification. QT-prolonging Agents may enhance the QTc-prolonging effect of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (including torsades de pointes). The option checked was, Disagree, and Please assess risk vs. benefit on the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions - Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The option selected by the physician was, Disagree. The form was signed by Physician #1 and dated 10/03/2025. There were no comments or explanations for declination written. Review of the Consultant Pharmacist Recommendations to Nursing Staff for Resident #2 dated 10/16/2025 read, MRR Date: 10/11/2025; Routing: Nursing - This resident is receiving the corticosteroid inhaler Advair. Please be sure to include in the plan of care that we're monitoring for throat irritation and oral thrush. Review of the Interim Medication Regimen for Resident #2 dated 11/03/2025 read, Consultant Pharmacist Recommendation to Physician: The following medication are best administered within these guidelines: Advair (Fluticasone-Salmeterol Aerosol Powder Breath Activated): Administration Instruction for Nursing: Rinse mouth after use; do not swallow, the option checked was, Disagree, and Please assess risk vs. benefit of the use of the following medications based on Drug/Drug, Drug/Food, Drug/Disease, Drug/Allergy interactions: Amiodarone + Lexapro: Per Lexicomp: consider therapy modification. QT-prolonging Agents may enhance the QTc-prolonging effect of Escitalopram. If use is necessary, monitor for QTc interval prolongation and arrhythmias (including torsades de pointes). Eliquis + Aspirin: Aspirin may enhance the adverse/toxic effect of Eliquis (Apixaban). Specifically, the risk of bleeding may be increased. Monitor patients closely for signs and symptoms of bleeding with any concurrent use. The options checked were both Disagree. The form was signed by the previous Medical Director and dated 11/05/2025. There were no comments or explanations for declination written. During an interview on 1/06/2026 at approximately 3:00 PM the DON stated that she did not know why [Physician #1's name] did not check agree, or defer to cardiology since the resident was being seen by them [cardiology]. During an interview on 1/072026 at 8:30 AM the DON stated that she was unable to locate any progress notes or physician explanation for declination of the multiple pharmacist recommendations for Resident #2. Regarding the one pharmacist recommendation directed to nursing, for Resident #2 to rinse her mouth after administration of Advair, she stated that she remembered entering the recommendation information somewhere but had not been able to locate it on her (the resident's) orders or associated with the MAR (Medication Administration Record). During an interview on 1/08/2026 at 12:45 PM Physician #1 stated that he did receive the forms with the pharmacist's recommendations, he reviewed and signed them. He usually does not disagree with the pharmacist's recommendations, but if he did disagree, he did not write a comment or explanation on the form. Review of the policy and procedure titled, Medication Regimen Reviews, with the last review date of 1/22/2025, read, Policy Statement: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 4. The goal of the MRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 10 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (Medication Regimen Review) is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: a. the resident's name; b. the name of the medication; c. the identified irregularity; and d. the pharmacist's recommendation. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. Review of Resident #10's Consultant Pharmacist Recommendations to Physician dated 9/22/2025 read, Recommendation: Consider dose reduction for Haloperidol to TID [three times a day] could possibly and potentially contribute to the falls episodes by causing syncope, orthostatic. Hypotension, dizziness and drowsiness. The Provider checked disagree and signed the form on 9/23/2025. The Physician did not provide a rationale. Review of Resident #26's Consultant Pharmacist Recommendations to Physician dated 8/9/2025 read, CMS Regulation. Per CMS guidelines, recommend reassessment of Phenergan 25 mg q 6 hr PRN [25 milligrams every 6 hours as needed after 14-day]. The Provider checked disagree and signed on 8/11/2025 but did not provide a rationale. Review of Resident #26 Consultant Pharmacist Recommendations to Physician dated 12/20/2025 read, Meds [medications]: Trazadone: Adverse Reactions (AR): Dizziness (20-28%), Drowsiness (24-41%), Fatigue (6-11%). Depakote AR: Dizziness (12-25%), Drowsiness (7-30%). Tamsulosin: AR: Dizziness (15-17%), Athenia (8-9%), Drowsiness (3-4^), Blurred Vision (<= 2%), hypotension) Metformin AR Dizziness (1-10%). Phenergan: sedated state, fatigue, blurred vision (Frequency not defined) Recommendations Change time of administrator for Tamsulosin to evening or bedtime. Consider dose reduction for Trazadone to 100mg HS. The Provider checked disagree and signed on 12/31/2025 but did not provide a rationale. Review of Resident #8's Consultant Pharmacist Recommendations to Physician dated 8/22/2025 read, Consider dose reduction for Trazodone to 25 mg HS [25 milligrams at bedtime]. Consider dose reduction for Gabapentin to BID [twice a day]. The Provider checked disagree and signed on 8/25/2025 but did not provide a rationale. Review of Resident #8's Consultant Pharmacist Recommendations to Physician dated 10/24/2025 read, Recommendations: Consider dose reduction for bedtime Seroquel 75mg HS [75 milligrams at bedtime]. Consider frequency reduction for Gabapentin to 100 mg q 12 hr [100 milligrams every 12 hours]. The Provider checked disagree and signed on 10/30/2025 but did not provide a rationale. During an interview on 1/8/2025 at 9:40 AM the Director of Nursing (DON) confirmed [Residents #2, #6, #8, #10, and #26] pharmacy recommendations did not include a rationale. The DON stated, Those recommendations were signed by the old doctor. Normally we do not expect to see a rationale included when the physician disagrees with the pharmacy recommendations because they are just recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 11 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician orders were followed for medication parameters for 1 of 6 residents, Resident #9, reviewed for medication management.Findings include: Review of Resident #9's physician order dated 2/2/2024 read, Losartan Potassium Tablet 25 mg [25 milligram] give 1 tablet by mouth two times a day for HTN [hypertension] Hold if BP [blood pressure] less than 90/50 or pulse less than 60 and notify MD [Medical Doctor].Review of Resident #9's Medication Administration Record (MAR) for the month of December 2025 for Losartan Potassium tablet 25 mg on 12/4/2025 at 2100 [9:00PM] pulse was 53 the medication was documented as administered, on 12/6/2025 at 0900 [9:00 AM] pulse was 58 the medication was documented as administered, 12/18/2025 at 0900 pulse was 59 the medication was documented as administered, 12/26/2025 at 900 pulse was 55 and at 2100 pulse was 56 and the medication was documented as administered, and on 12/27/2025 at 2100 pulse was 54 and the medication was documented as administered.Review of Resident #9's MAR for the month of [DATE] for Losartan Potassium tablet 25 mg on 1/1/2026 at 2100 pulse was 58 the medication was documented as administered. During an interview on 1/8/2026 at 9:45 AM the Director of Nursing stated, I expect nurses to follow the physician orders and call the provider if they have to clarify an order. The order was done by the old provider that over saw the facility.During an interview on 1/8/2026 at 11:07 AM Staff F, Licensed Practical Nurse stated, A check mark means medication is given.During an interview on 1/8/2026 at 1:32 PM the Advanced Practice Registered Nurse #1 stated, Nurses are to follow physician orders as given and contact us with any questions.Review of the facility policy and procedure titled Administering Medications with a last review date of 1/22/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 12 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 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, and record review the facility failed to prevent the possible spread of infection for 1 of 4 residents, Resident #26 reviewed for respiratory service, 1 of 4 residents, Resident #11, reviewed for enhanced barrier precautions, 1 of 5 medication observations, Resident #13, and during dining.Findings include: During an observation on 1/5/2026 at 10:20 AM Resident #11's room door had an enhance barrier sign posted and personal protective equipment hanging outside of the room door. Resident #11 was sitting in his wheelchair. Staff B Certified Nursing Assistant (CNA) was inside of the room making the residents bed with only gloves on and no gown. Staff B, CNA collected the soiled linen on the floor in front of the resident's bathroom and placed the linens in a transparent plastic bag. Review of Resident #11's physician orders did not include orders for enhance barrier precautions. Review of Resident #11's physician order dated 1/2/2026 read, Tx [treatment] Sacrum: Cleanse with n/s [normal saline], pat dry. Apply anasept gel and collagen powder to wound bed, cover with ca [calcium] alginate and dry dressing daily and prn [as needed]. Review of Resident # 11 [Name of the wound care physician] wound evaluation and management summary dated 1/2/2026 read, focused wound exam stage 4 pressure wound sacrum full thickness. During an interview on 1/8/2026 at 9:45 AM the Director of Nursing (DON) stated, Staff is supposed to wear a gown and gloves when providing care. That includes when the staff is making the resident's bed and touching linen that had been on the bed. [Resident #11's name] is on enhance barrier precautions due to the pressure ulcer he has. Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 1/22/2025 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of [NAME]-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: e. changing linens. During an observation on 1/5/2026 at 12:25 PM Staff B, CNA removed Resident #3's tray from the dietary cart and delivered the tray to the resident in the common area. Staff B, CNA assisted the resident in setting up the meal. Staff B returned to the dietary cart and without hand sanitizing removed Resident #41's tray and delivered the tray to the common dining room and assisted Resident #41 with meal set up. Staff B without sanitizing her hands returned to the dietary cart and removed Resident #67's meal tray and delivered the tray to the resident, Staff B offered to cut the meat for the resident which the resident accepted the help. Staff B returned to the meal cart and sanitized her hands using the sanitizing dispenser. During an interview on 1/7/2026 at 9:55 AM the DON stated, Staff should wash or sanitize their hands in between residents. During an interview on 1/8/2026 at 1:10 PM Staff B, CNA stated, You wear a gown and gloves when providing care to the resident. I normally wear a gown, I probably forgot. I always use hand sanitizer after each resident, I cannot remember. I probably forgot to use hand sanitizer. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 1/22/2025 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. During an observation on 1/7/2026 at 8:30 AM Staff C, Registered Nurse (RN) entered Resident #26's room to take the residents vitals. Resident #26 was sitting in his wheelchair, there was a nasal cannula on the floor. Staff C, RN proceeded to pick up the nasal cannula and place it on Resident #26's nose. During an interview on 1/7/2026 at 8:44 AM with Staff C, RN, stated, I should have not placed the nasal cannula back on the resident after I found it on the floor. I should have cleaned it or gotten a new one. Review of Resident #26 physician order dated 1/2/2026 read, Continuously 02 @ 2L/M [oxygen at 2 liters per minute] for SOB [shortness of breath] every day and night shift for SOB. During an interview on Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105808 If continuation sheet Page 13 of 14 Printed: 05/28/2026 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 105808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Crescent Lake 100 N Lake St Crescent City, FL 32112 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1/7/2026 at 9:56 AM the Director of Nursing stated, The staff should pick up the nasal cannula that was found on the floor and throw it away and go get a new one. Anything that falls on the floor goes in the trash. During an observation on 1/7/2026 at 8:59 AM Staff D, Licensed Practical Nurse (LPN) prepared Resident #13's medications and donned gloves, gown and a mask before entering the resident's room. Staff D checked for placement and residual before administering the medications into Resident #13's gastric tube and proceeded to also administer a bolus feeding. Staff D removed the syringe and did not rinse the syringe after using it and placed the syringe back in the plastic bag. The tip of the flush syringe had visible residue at the time of the medication administration and feeding. During an interview on 1/7/2026 at 9:17 AM Staff D, Licensed Practical Nurse (LPN) stated, I should have rinsed off the flush syringe after the administration and make sure all the junk is gone. During an interview on 1/7/2026 at 9:56 AM the Director of Nursing stated, The nurse should have rinsed the gastric tube flush syringe after use and then store it. Review of the policy and procedure titled Administering Medications through an Enteral Tube with a last review date of 1/22/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 7. Use a clean enteral syringe with an ENFit [safety connector for enteral feeding tubes] connector to administer medications through an enteral tube. Event ID: Facility ID: 105808 If continuation sheet Page 14 of 14