Inspection·July 27, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and staff for the control or detection of infectious diseases when: The facility is experiencing an outbreak; or Directed by the Department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, epidemics, or pandemics. The facility's General guidance for Managing an Outbreak, Revised 6/2022, documents An Outbreak is Generally Defined as: .Occurrence of three (3) or more cases of the same infection over a specified period of time an in a defined area . food poisoning is defined as two (2) or more cases in persons who shared the same meal . diarrhea is defined as anything exceeding the endemic rate, or a single case if unusual for the facility. The Administrator or designee will be responsible for: Telephoning a report to the health department. The Infection Preventionist and Director of Nursing Services will be responsible for . notifying the Medical Director and the Attending Physicians. The nursing staff will be responsible for notifying the Director of Nursing Services of symptomatic residents; Providing infection surveillance data in a timely manner; Initial testing or obtaining laboratory specimens as directed . Initiating isolation precautions as directed or as necessary. If an outbreak is identified, personnel will be responsible to: Notify Administrator, DON (Director of Nursing)/designee, IP and/or Medical Director of any unusual signs and symptoms or events . Follow Core Principals of infection prevention and control . Use PPE appropriately . Notify their supervisor immediately if any new case is suspected both residents and staff. The facility's Stool Cultures in a Suspected Enteric Organism or Food-borne Outbreak, Revised 6/2022, documents An outbreak of suspected food-borne illness is defined as three (3) or more residents with clinically significant diarrheal or loose stools that occur within 24 hours of each other who have common exposure to each other, or share common space, or have consumed the same food. When an outbreak is suspected, the facility takes immediate action to confirm diagnosis and investigate appropriately. 1. When an outbreak is suspected, a stool specimen will be sent to the laboratory for culture and sensitivity. Any residents or staff who exhibit similar symptoms after that time also will have stool samples sent to laboratory for culture and sensitivity. 2. Enteric (food-borne) pathogens should be considered under these circumstances and would include Salmonella, shigella, Campylobacter, and E. Coli etc. 3. Until lab results are available, isolation precautions should be considered and residents who are ill should be assisted to perform good hand hygiene after a stool, should not be included in the dining room, recreational activity, or other group activities until symptoms resolve. 4. Staff exhibiting symptoms should be sent home pending lab results and symptoms resolved. 5. The Infection Preventionist has the authority to order these cultures under the direction of the Medical Director. The facility's Surveillance & Investigation policy and procedure, dated 5/2022, documents Infections that should be included in routine surveillance include those with . a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection . d. Specific pathogens that are associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza.). If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse and Infection Preventionist immediately. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification . The Charge nurse will notify the Attending Physician and the Infection Preventionist of suspected infections . When transmission of Healthcare-Associated Infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or specialist in infection control and epidemiology will be consulted for further recommendations. The facility's HCW (Healthcare Worker) Self-Reporting of Infection policy and procedure, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 - Many 6/2022, documents As part of the facility infection prevention program it is the employee's responsibility to notify their supervisor or the Infection Preventionist of any identified or potential infection with an infectious disease . In compliance with our established policies governing employee health, you must report the following conditions to your supervisor, or to the Infection Preventionist: 1. Temperature of 100 degrees Fahrenheit or greater; 2. Nausea/Vomiting; 3. Acute diarrheal illness (severe) with other symptoms (i.e., fever, abdominal cramps, bleeding, etc.) or diarrhea lasting longer than twenty-four (24) hours . 13. Any other conditions as required by the (State Agency) or CDC. 14. Failure to comply with reporting will result in disciplinary action. The facility's Isolation - Categories of Transmission - Based Precautions, Revised 1/2014, documents Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis . wear gloves when entering the room . wear a disposable gown upon entering the Contact Precautions room. The facility's Contact Precautions policy and procedures, Revised 5/22, document: Contact Precautions are intended to prevent transmission of infectious agents, like MDRO's (Multiple Drug Resistive Organisms), that are spread by direct or indirect contact with the resident or the resident's environment. In addition to Standard Precautions, use Contact Precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . Contact Precautions may be considered for residents who have: 4. diarrhea and fecal incontinence, or 5. Other epidemiologically significant organisms as determined by the facility's Infection control staff and Medical Director. Masks and eye protection, under Standard Precautions, should be worn during resident care activities that are likely to generate splashes of sprays of blood, body fluid, secretions, and excretions. The facility's I-NEDSS (Illinois' National Electronic Disease Surveillance System) Infectious Disease Reporting policy and procedure, dated 5/22, documents Should any resident (s) or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to State-specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials. If the disease or condition is also listed as a Nationally Notifiable Infectious Disease according to the CDC (Centers for Disease Control), the Infection Preventionist, or designee, shall notify the CDC of the occurrence(s). All reportable infectious diseases (residents' or employees') must be reported to the infection Preventionist as soon as definite diagnosis is made or strongly suspected . Infectious Diseases Reportable Immediately by Telephone include: Any unusual case or cluster of cases that may indicate a public health hazard . Botulism, foodborne . Influenza A, variant. The facility's Infection Control Guideline for the Dietary Department, Revised 1/2014, documents Dietary staff: 1. Maintain good health . 6. Are monitored for compliance with policies, procedures, and practices . 8. Do not work if they are ill with a gastrointestinal illness, or have been diagnosed with a food-borne illness. On 7/20/23 at 1:30 pm there was no signage at the entrance of the facility informing visitors that the facility was currently in outbreak status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 - Many The facility's Outbreak Line Listing, provided on 7/20/23, documents two symptomatic residents on 7/17/23 (R10 and R11); 28 residents on 7/18/23 (R3, R5, R7, R9, R12 thru R35); and 14 residents on 7/19/23 (R2, R4, and R36 thru R47); and three residents on 7/20/23 (R1, R6, and R48). The Outbreak Line Listing, provided on 7/21/23, documents three additional symptomatic residents (R8, R49 and R50). The Outbreak Line Listing, provided on 7/26/23 documents one additional symptomatic resident (R51) was added on 7/23/23; one additional symptomatic resident (R52) was added on 7/24/23; and one additional resident (R53) was added on 7/26/23. The facility's Outbreak Line Listing, provided on 7/26/23, documents the first symptomatic staff member was V7 Assistant Dietary Manager, with onset of 7/13/23 with fever, diarrhea, nausea, muscle aches, and fatigue. The second symptomatic staff member was V20 [NAME] for second shift, with onset date of 7/14/23 with diarrhea, nausea and fatigue. The third symptomatic staff member was V21 Dietary Manager, with onset date of 7/17/23 with vomiting, fever, and diarrhea. On 7/20/23 at between 1:30 pm through 3:05 pm, a tour of the facility was completed. There was no Outbreak signage noted at the entrance to the facility and no staff were visible wearing masks, gowns, or gloves in common areas, on the hallways, or when entering resident rooms. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak: 200 Wing identified R35; 500 Wing identified R2, R4, R9, R10, R12 through R17, R36 through R42; 600 Wing identified R43 through R47; 800 Wing identified R3, R18 through R30 and 400 Wing identified R4 and R31 through R34. At the entrance to the 400 Wing (Alzheimer's locked unit) a sign was posted to the door that read Guests: Masks are to be worn at all times. After entering the 400 Wing staff, various residents, and visitors were noted throughout the open floor plan and in resident rooms not wearing any PPE. On 7/21/23 at 9:00 am, a sign announcing Facility is in Outbreak was noted on a table in front of the entrance door in an eight by ten frame and was not visible until after entering the facility automatic double doors. On 7/21/23 between 12:00 pm through 1:00 pm, a tour of the facility was completed. During this tour there were multiple staff wearing masks in all areas of the facilities, visitors not wearing masks and random staff not wearing masks in the hallways and common areas. The facility Wings identified the following wing and Residents as being in isolation for the facility's Outbreak; 200 Wing identified R8 and R50; 500 Wing did not identify any residents this day; 600 Wing identified R6 and R47; 800 Wing identified R1 and R3 and V R3's Family Member was visiting R3 and walked to the community dining area without wearing PPE; and 400 Wing identified R4, R31, R48 and R49. On this same date at 12:30 pm, the 800 Wing dining room had residents being served the noon meal. R26 and R29 who were previously symptomatic on 7/18/23 were being assisted in the dining room. On 7/20/23 at 1:30 pm, V1 Administrator stated the facility is currently in an outbreak status and the LHD (Local Health Department) came and just left and is helping us. V1 stated the facility started an investigation on 7/19/23 and feel it started with V7 Assistant Dietary Manager who had symptoms but didn't think it was a big deal and worked anyway. That's how it happened. V1 stated three kitchen staff and a CNA (Certified Nurses Aide) were symptomatic first. V1 stated a few residents were sent to the local hospital but not GI (gastrointestinal) symptoms. V1 also stated there was one resident who passed away who had vomited one hour prior to passing but she had not been sick. V1 stated the LHD reached out to her yesterday (7/19/23) morning and came to the facility today to investigate and help and just left the facility. V1 Administrator stated the facility did not report to the LHD or the State Agency because the LHD called her on 7/19/23 so they were aware. V1 stated she has no confirmed tests for Noroviurs but is treating it as Norovirus. V1 stated first symptomatic residents exhibiting symptoms was on 7/17/23. V1 stated the facility collected and sent stool samples out for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 - Many R1, R2, and R9 but has not received results yet. Confirmed Outbreak rooms are identified with Orange Stock paper with black I due to not have enough regular Isolation signs to use. On 7/20/23 at 2:48 pm, V7 Assistant Dietary Manager stated on 7/13/23 he was having some bodyaches and a low grade temperature but he felt ok, tested for COVID and it was negative, called his supervisor and was told to go ahead and go into work. V7 stated later in the day I had a diarrhea stool but that is not out of the ordinary for me due to my stomach issues. V7 stated the next day (7/14/23) he still had body aches and diarrhea but went to work and confirmed he did not call his supervisor. V7 stated he was off the weekend (7/15 and 7/16) and returned to work on Monday (7/17/23) without symptoms. V7 stated that V20 [NAME] for second shift went to the doctor on 7/12/23 and reported that the doctor tested her for strep and it was positive, got medicine and then returned to work on Wednesday (7/17/23) and worked through 7/19/23 and was sent home today (7/20/23) due to having diarrhea. V7 Assistant Dietary Manager also stated V21 Dietary Manager called in on Monday (7/17/23) because she wasn't feeling well and came back to work yesterday (7/19/23) to do inventory and then got sent home. V7 stated he had been around his best friends daughter who had thrown up a couple of times and wonders if he maybe he got something from her. V7 stated symptomatic residents are eating in their rooms and everyone else eats in the dining room. On 7/21/23 at 9:00 am, V1 Administrator stated Health Department had a meeting with (State Agency) yesterday and the Health Department told us to stop the dining room meals and now all residents are eating in their rooms. V1 Administrator stated V21 Dietary Manager went to her doctor yesterday and was told she had a stomach virus but did not test V21. V1 also stated the facility is still waiting for the stool culture results for R1, R2, and R9 and the lab said it could take two to five days to get results. On this same date at 10:02 am V1 Administrator stated as of noon yesterday (7/20/23) everyone is eating in their rooms and we placed a sign at the entrance table for visitors, and all staff have been inserviced and should be wearing mask, gown and gloves when entering symptomatic resident rooms and washing their hands before exiting the residents room. On this same date at 11:37 am, V1 Administrator stated the virus seems to have started with V7 Assistant Dietary Manager who has chronic IBS (Irritable Bowel Syndrome) and not sure what to do about that. V1 also stated We are keeping everyone in isolation until 48 hours after they are symptom free. The same with staff. On 7/21/23 at 9:34 am, V6 LPN (Licensed Practical Nurse)/IP (Infection Preventionist) stated an investigation was started on 7/19/23 because there were so many people who became symptomatic. V6 LPN/IP stated We traced it back to V7 Assistant Dietary Manager in the kitchen, who said that he had to relieve himself during one of the meal services. V6 stated It started in the kitchen with V7 Assistant Dietary Manager, so he didn't do something right. V6 LPN/IP stated the CNA's and Nurses were told if someone had a loose stool they were supposed to let me know so we could stool/emesis samples but by the time we got down there it was either on the floor, in the garbage can, or the staff had already cleaned it up. I was not going to get a sample off the floor or from the garbage can. V6 LPN/IP stated stool samples were obtained from R2 and R9 on 7/19/23 and from R1 on 7/20/23. On 7/26/23 at 12:30 pm, V2 DON (Director of Nursing) stated she worked the morning of 7/19/23 on the 800 wing and was not aware of any of the residents having symptoms until that morning upon arriving at the facility. V2 stated generally the staff call about everything and I would have expected them to notify myself and V6 LPN/IP. They did not notify V6 LPN/IP either. V2 DON stated, I called V54 Medical Director on the morning of 7/19/23 and told (V54) what was going on with symptomatic residents on the 500 and 800 wings and asked if we could do Norovirus tests and he said to go ahead and get stool samples. (V54) said we should do four or five. V2 DON stated As of 7/19/23 we kept everyone symptomatic in their rooms in contact isolation with sign and bin outside their room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 - Many V2 DON stated residents who were not symptomatic were able to be in the dining room separated from others and everyone was to wear a gown, gloves, and mask in symptomatic resident rooms. V2 DON stated we had two residents with symptoms on the 17th but it is not abnormal for some residents to have diarrhea. The evening of 7/18/23 is when everything really started happening. I was not aware. I do feel that if things would have been started earlier, or we would have known, we could have helped stop the rapid spread of this virus. On 7/25/23 at 2:55 pm and 7/26/23 at 2:30 pm, V21 DM (Dietary Manager) stated she does not recall V7 Assistant Dietary Manager calling in to work sick this month. V7 Assistant Dietary Manager comes to work, does his job, and knows if he is sick he should not be working. V21 DM stated she was on vacation the week of 7/17/23 and is not aware of anyone working while being sick or they would have been sent home, no one reported anything to her, and stated they all (dietary staff) know that if they are ill with nausea, vomiting, diarrhea or fever they cannot work. V21 stated she did not know that V7 Assistant Dietary Manager had not been feeling well until she returned from her vacation. V21 DM stated V65 Dietary Aide/Cook did call her on Sunday 7/10/23 while (V21) was on vacation and (V21) told V65 that she would need to call V7 Assistant Dietary Manager. V21 stated she did remind V65 that it is her scheduled weekend staff are supposed to try and find their own replacement before calling in and all V65 said was she was not going to be able to find anyone to work and said I'll just go to work. V21 DM stated This to me is that you're not really sick or you wouldn't be going to work. V21 DM stated again, They all know that if they are ill with nausea, vomiting, diarrhea, fever they cannot work. V21 DM stated she did not know what happened while she was gone on vacation. 1. The Quarterly MDS (minimum data set) assessment, dated 5/6/23, documents R1 is cognitively intact, requires extensive assist of one with bed mobility, transfers, walking, locomotion, toileting, personal hygiene, and bathing and limited assist with set up for eating. R1 is frequently incontinent of urine and occasionally incontinent of bowel. The current Care Plan for R1, documents (R1) is on contact isolation related to Norovirus symptoms. The Order Summary Report, dated 7/21/23, documents Clear liquid diet every shift until 7/21/23 1:59 am and Contact Isolation every shift until 7/21/23. On 7/20/23 at 3:20 pm, R1 was in lying in her bed with isolation signage posted to the frame of her door. On 7/21/23 at 1:18 pm, R1 was sitting up in a wheel chair in her room with the same isolation signage posted on door frame. On 7/21/23 at 1:18 pm, Entered R1's room with gown, gloves, and mask on. When asked R1 if staff wear gown, gloves, and/or mask in her room, R1 stated, Oh no, no one has come in here dressed like you, this is the first I have seen. No one has worn a gown or gloves into my room, just a mask. R1 stated, I was so sick. Have never had such extreme diarrhea ever in my life. It was diarrhea on top of diarrhea. The Nurse told me it was some kind of flu. R1 stated a stool sample was sent to the laboratory yesterday and she has not heard any results yet. R1 also stated her son got sick after visiting her. The Progress Note for R1, dated 7/19/23 at 4:19 pm, documents Resident c/o (complained) of diarrhea. Loose, watery brown colored stool noted in toilet. No other GI (gastrointestinal) c/o at this time. The Note, dated 7/20/23 at 8:02 am, documents Stool sample collected at this time d/t (due to) diarrhea. The Note, dated 7/20/23 at 10:52 am, documents Covid swab completed with negative result. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 Note dated, 7/20/23 at 2:16 pm, documents POA (Power of Attorney) and MD (Medical Doctor) notified. Level of Harm - Minimal harm or potential for actual harm The Laboratory results for R1's stool sample, dated 7/22/23 documents stool specimen obtained on 7/20/23 with diagnosis listed as Diarrhea, unspecified. The Final result for Norovirus PCR (polumerase chain reaction) test: Test not performed and Canceled on 7/22/23 at 2:23 pm; Incorrect collection container submitted. Residents Affected - Many 2. The Quarterly MDS for R2, dated 5/22/23, documents R2 is cognitively intact, requires limited assist of one for bed mobility, locomotion, and personal hygiene. R2 requires extensive assist of one for transfers, toileting, and bathing. R2 requires limited assist with set up for eating and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R2, does not document anything for R2 regarding the facility's current outbreak or isolation precautions. The Order Summary for R2, dated 7/21/23, does not document any orders regarding the facility's current outbreak. On 7/20/23 at 2:14 pm, R2 was lying in bed with visitors in his room who were not wearing PPE. Isolation signage was on the door frame. On 7/21/23 at 12:30 pm, R2 was sitting up in a wheel chair in his room eating lunch. On 7/21/23 at 12:46 pm, R2 stated the day before yesterday (7/19/23) he had diarrhea for about half of the day and the facility only fed him bread and water. R2 stated he doesn't understand what has been going on and doesn't like it. It was only half a day and then I was fine, nothing else. R2 stated his roommate had it worse than (R2) but is better now. R2 stated They (staff) don't know what is going on here. Someone said they think it was food poisoning but no one will say and they won't let us come out of our room now. I just find it all crazy. The Progress Note for R2, dated 7/19/23 at 11:21 am, documents R2 received Tylenol. The Note at 4:02 pm, documents Resident presents with diarrhea, low grade temp (temperature), Tylenol given. POA and APN (Advance Practice Nurse) aware. The Note at 4:36 pm, documents Resident swabbed for Covid 19, results negative. The Note at 6:14 pm, documents Stool obtained, sent to lab. The Laboratory results for R2's stool sample, dated 7/22/23, documents stool specimen obtained on 7/19/23 with diagnosis listed as Acute gastroenteropathy due to other. The Final result for Norovirus PCR test: Test not performed and Canceled on 7/22/23 at 2:27 pm; Incorrect collection container submitted. 3. The Annual MDS for R3, dated 5/18/23, documents R3 has moderately impaired cognition and requires extensive assist of two staff for bed mobility, transfers, walking, and toileting; requires extensive assist of one for locomotion, personal hygiene and bathing and supervision with set up assist for eating; and is occasionally incontinent of urine and always continent of bowel. The current Care Plan for R3, documents R3 was hospitalized and received IV (intravenous) fluids for hydration. R3's Care Plan does not address the facility's current outbreak or isolation status for R3. The Hospital discharge records for R3, dated 7/20/23, documents R3 was hospitalized from [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 through 7/20/23 with diagnoses: Respiratory Insufficiency and Hypoxemia and returned to the facility on antibiotics. The Order Summary Report for R3, dated 7/21/23, does not include isolation orders or any orders regarding the facility's current outbreak status. Residents Affected - Many On 7/20/23 at 3:19 pm, R3 was lying in bed, no isolation signage to room. On 7/21/23 at 1:10 pm, R3 was sitting up in a wheel chair in her room with an isolation sign posted to the door frame of her room. V19 R3's Family Member was visiting without wearing PPE. On 7/21/23 at 1:55 pm, V19 R3's Family Member exited R3's room, without performing hand hygiene and walked to the empty dining area. On 7/21/23 at 1:55 pm, R3 stated she had diarrhea before she went to the hospital and hasn't had any since she came back. R3 stated she wasn't sure why she went to the hospital. On 7/21/23 at 2:00 pm, V19 R3's Family Member stated (R3) only had diarrhea one day and went to the hospital and I don't know why she is in isolation. V19 did state the facility had informed him of the facility outbreak status. The Progress Note for R3, dated 7/18/23 at 6:30 am, document Nausea, vomiting and diarrhea. Anti diarrheal medication given. In bed, eyes closed at this time, Call light within reach. Colace and Miralax (medications) held due to diarrhea. The Note at 1:02 pm, documents Resident seen by V60 NP (Nurse Practitioner). No new orders noted. The evening doses of Colace and Miralax held. The Progress Note for R3, dated 7/19/23 at 10:22 am, documents Observed resident in bed HOB (head of bed) elevated responding lethargically. Vitals taken. Temp (temperature) 98.0, B/P (blood pressure) 93/61, P (pulse) 85, R (respirations) 15, SpO2 (blood oxygen level) 83%, (V61) NP notified. Supplemental oxygen started at 2L (liters) via nasal cannula. The note at 10:48 am, documents SOB (shortness of breath), lethargic, altered mental status. The Note at 10:52 am, documents New order to send to ED (emergency department) per (V61 NP). 911 here to transport. Call placed to (V19 R3's Family Member.) The Progress Note for R3, dated 1/19/23 at 11:06 am, V60 NP documented NP was called to see (R3) because of altered mental status and low oxygen saturations. Yesterday (7/18/23) she had GI symptoms of vomiting and diarrhea. This morning the nurse noticed she was more out of it and not acting herself. She (R3) is usually up in her chair and talking. This morning she did not want to get out of bed. She is having a hard time answering questions and following commands. Her oxygen saturation was initially 83% and she was placed on 2L. When I (V60 NP) arrived she was only at 87-88% and titrated her (R3) oxygen up to 4L and she eventually came up to 95%. She (R3) still could not follow commands and was very slow to respond to questions. She knew her birthday but not where she was or the year. 911 was called and she was sent out with EMS (emergency management systems.) . Altered mental status: Acute, unstable . Low oxygen saturation: Acute, Unstable continue 4L nasal cannula. Send to ER (emergency room) via 911 . Diagnoses: 1.) Altered metal status, unspecified. 2.) Hypoxemia. The Laboratory reports for R3 do not include any stool specimens being collected or sent to the facility lab. 4. The Quarterly MDS for R4, dated 5/2/23, documents R4 with moderately impaired cognition, requires extensive assist of two staff for bed mobility, dressing, toileting; totally dependent of two staff for transfers and bathing; extensive of one staff for eating and personal hygiene; and is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Ottawa 704 East Glover Street Ottawa, IL 61350 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 frequently incontinent of urine and bowel. Level of Harm - Minimal harm or potential for actual harm The current Care Plan for R4 documents (R4) is on contact isolation related to Norovirus symptoms. Residents Affected - Many The Order Summary Report for R4, dated 7/21/23, documents order 7/21/23 Clear liquid diet every shift until 7/22/23 1:59 am. No isolation orders are included in R4's current physician orders. On 7/20/23 at 2:22 pm, R4 was lying in bed. No Isolation signage is posted to R4's door or door frame. On 7/21/23 at 1:00 pm, R4 was lying in bed with isolation signage posted to R4's door frame. V62 CNA (Certified Nursing Assistant) was standing[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 9 of 9