Health inspection·September 29, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility and strictly follows what her doctor told her to do. R78 stated she is on a 1500 ml fluid restriction and uses the same 8 ounce mug she used at home so she can track her fluid intake easily. R78 stated she does not take the water from the nurse to drink with her medications and uses her own mug water. R78 stated she rents a BiPap machine from a local company who comes to the facility monthly to check the machine and change the tubing and mask. R78 stated no staff have cleaned her tubing or mask since she came to the facility. The current POS (Physician Order Sheet) for R78 documents 1500 ml (milliliters) Fluid Restriction every day; Breakfast 420 ml; Lunch 400 ml; and Nursing 200 ml for total of 1020 ml for day shift. Dinner 180 ml and Nursing 200 ml for total of 380 ml. Every night shift 100 ml. Record total amount consumed in 24 hours 1500 ml. The current Care Plan for R78, documents R78 with a 1200 ml Fluid Restriction; 720 ml from dietary and 480 ml from nursing daily and was not revised to the current 1500 ml Fluid Restriction order. This same Care Plan does not include cleaning of or cares for R78's BiPap machine and equipment. On 9/29/23 at 2:15 pm, V7 MDS Coordinator confirmed R78's fluid restriction and Bipap machine were not correct/identified on R78's Care Plan and should be. Based on observation, interview, and record review, the facility failed to revise Care Plans to be resident specific for five (R10, R12, R20, R78, and R108) of 25 residents reviewed for Care Plan revision in a sample of 31. Findings include: The facility's Care Plans, Comprehensive Person-Centered Policy, dated 4/2017, documents Policy Statement: A comprehensive, person-centered care pan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. On 9/26/23 at 11:13am and on 9/28/23 at 11:00am, R12 was lying in bed with her CPAP (Continuous Positive Airway Pressure) mask on and machine running. R12's current Physician Order Sheet/POS documents CPAP every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. R12's current Care Plan does not include any cleaning of or cares for the CPAP machine and equipment. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator confirmed that R12's Care Plan does not include any care of R12's CPAP machine and it should. 2. On 9/26/23 at 9:56am, R108's room had oxygen tubing and a humidifier dated 9/24/23. On 9/27/23 at 11:30am and 9/28/23 at 3:08pm, R108 was in her room with oxygen on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 2 of 10 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 09/29/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete R108's current order summary report, dated 9/29/23, documents Oxygen per Nasal Cannula at (3) L/min (liters/minute) continuous every shift with an order date of 7/28/23. R108's current care plan does not include her oxygen use. On 9/29/23 at 12:19pm, V13 MDS/Minimum Data Set Director stated I just updated (R108's) care plan yesterday to include her respiratory and oxygen status. It should have been on the care plan. Event ID: Facility ID: 145426 If continuation sheet Page 3 of 10 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 09/29/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 3. On 9/28/23 at 10:10 am, a BiPap machine was resting on R78's night stand with the tubing and mask resting over top of the machine. Residents Affected - Few On 9/28/23 at 10:15 am, R78 stated her tubing and mask are not being cleaned regularly. The current POS (Physician Order Sheet) for R78, documents BiPap 12/5/5% Frequency: HS (hour of sleep) every evening and night shift. On 9/28/23 at 11:30 am, V7 MDS (Minimum Data Set) Coordinator stated respiratory equipment should be cleaned routinely. Based on observation, interview, and record review, the facility failed to ensure a respiratory treatment was administered according to facility policy for one (R54) of one residents reviewed for breathing treatments during medication administration; and failed to ensure a residents respiratory equipment is routinely cleaned for two (R12 and R78) of four residents reviewed for respiratory care in a sample of 31. Findings include: 1. The facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 11/2013, documents The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds .16. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. When treatment is complete turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .23. Obtain post-treatment pulse, respiratory rate and lung sounds. 24. Rinse nebulizer pieces after use: a. Wash pieces with warm water. b. Allow to air dry on a paper towel .26. When equipment is completely dry, store in a plastic bag with the date on it. R54's current Physician Order Sheet/POS documents an order for Ipratropium Bromide & Albuterol 0.5mg (milligrams)/3mg per 3ml (millimeters) vial. One vial inhale orally four times a day related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Rinse nebulizer set-up after each use and allow to dry. Once dry put in plastic bag with residents name and date. On 9/27/23, at 11:08am, R54 was lying in bed. V9 Registered Nurse/RN put Ipratropium Bromide & Albuterol liquid in the nebulizer medication cup, handed R54 the mouth piece, then turned on the nebulizer machine and left the room. At this time, V9 stated that V9 typically does not stay in the room during the treatment if the resident can do the treatment by themselves. (R54) is very good and will even shut it off by herself when done. On 9/27/23, at 11:21am, V9 returned to R54's room and waited two to three minutes for the treatment to be completed. V9 turned off the nebulizer machine. R54 handed V9 the mouth piece. V9 rinsed the medicine cup and mouth piece with water, shook off excess water, then attached them to the tubing and put them back into R54's blue canvas bag on R54's bed. On 9/27/23, at 2:26pm, V9 RN stated that this is her normal way of administering a nebulizer treatment. I only listen to their lungs if there is a problem or reason to, or if they were recently put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 4 of 10 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 09/29/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on nebulizer treatments. I usually rinse it then shake it out and place it back in (R54's) bag without letting it air dry on a paper towel. On 9/28/23, at 2:15pm, V2 Director of Nursing/DON stated the following: It is expected for the nurse to stay in the room during nebulizer treatments or return periodically to monitor the resident, and to assess lungs and vitals before and after the treatment. Staff are expected to rinse the nebulizer equipment with water, and let it dry on a paper towel. 2. The facility's CPAP/BiPAP (Continuous Positive Airway Pressure/BiLevel Positive Airway Pressure) Support policy, dated 11/2014, documents General Guidelines for Cleaning: 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device .4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): b. Clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. 6. Filter cleaning: a. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. b. Replace disposable filters monthly. 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to dry. R12's current Physician Order Sheet/POS documents Cpap every shift - patient may apply and remove per self at bedtime and when napping with oxygen at 4 liters to bleed (flow) in. On 9/26/23, at 11:13am, R12 is lying in bed with the CPAP on. R12 stated that her CPAP equipment does not get cleaned and has not been changed for six months. On 9/28/23, at 11:00 AM, V12 Registered Nurse/RN was unable to find any parameters for routine cleaning of R12's CPAP in R12's clinical record; V12 is unaware of cleaning being done. On 9/28/23, at 11:24am, V7 Minimum Data Set/MDS Coordinator V7 stated that R12's CPAP nasal mask and tubing was replaced in June, but R12's CPAP equipment should be cleaned routinely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 5 of 10 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 09/29/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review the facility failed to ensure a diagnosis, targeted behaviors, and indication for the use of an antipsychotic medication was in place for a resident with Dementia for one (R10) and failed to ensure a PRN (as needed) psychotropic medication did not exceed a duration of 14 days without a physician evaluation and rationale for continued use for one (R20) of five residents reviewed for unnecessary medications in the sample of 31. Findings include: The facility's Psychotropic Medication policy and procedure, dated 11/2013, defines This same policy defines A psychotropic drug is any drug that affects brain activities associated with mental processed and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotics, anti-depressants, anti-anxiety and hypnotics. This same policy documents The prescribing and administration of psychotropic drugs is based on a comprehensive assessment of the resident. Residents who have not used psychotropic dugs are not given these dugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents must be free of unnecessary drugs. (Unnecessary drugs are any drug when used in excessive dose, excessive duration, without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued.) Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: Schizophrenia; Schizo-affective disorder; Schizophreniform disorder; Delusional disorder; Mood disorders (e.g. bipolar disorder, depression with psychotic features, and major depression); Psychosis in the absence of dementia; Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids); Tourette's Disorder; Huntington Disease; Hiccups, Pruritus (for short term of 7 days); or nausea and vomiting associated with cancer or chemotherapy. Residents do not receive psychotropic drugs pursuant to PRN/as needed orders unless that medication is necessary to treat a diagnosed specific condition. PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of the medication and documents their rationale for continued use in the resident's medical record for the duration of the PRN order. 1. The Order Summary Report for R10, dated 9/28/23, lists the following diagnoses: Dementia with behavior disturbance, Restlessness and Agitation, and Anxiety Disorder. This same Report documents a Physician Order for the Antipsychotic medication Quetiapine Fumarate 25 mg (milligrams): Give 0.5 (half) tablet by mouth at bedtime every Monday, Tuesday, Wednesday, Thursday, Friday and Sunday for potential for harm to self or others related to Dementia with behavioral disturbance. The Order Summary Report for R10, dated 9/28/23, also documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 6 of 10 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 09/29/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The CNA (Certified Nursing Assistant) electronic computer charting system does not document any identified targeted behaviors for R10 that are to be monitored. Residents Affected - Few The MAR (Medication Administration Record) for R10, dated July through September 2023, documents the same generic list of behaviors in R10's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R10 to be documented. The Quarterly MDS Assessment, dated 11/1/22, documents R10 as cognitively intact, with no identified behaviors, and no SMI (Serious Mental Illness) diagnoses. The Quarterly MDS Assessment, dated 12/31/22, documents R10 with moderately impaired cognition with no identified behaviors, and no SMI diagnoses. The Quarterly MDS Assessment, dated 4/1/23, documents R10 as cognitively intact, with no identified behaviors, and no SMI diagnoses. The Annual MDS (Minimum Data Set) Assessment, dated 7/1/23, documents R10 is moderately impaired for cognition, 1 to 3 days for rejection of cares, and no SMI diagnoses. The current Care Plan for R10 documents, date initiated 5/12/2020 Focus area as: (R10) Uses psychotropic medication Quetiapine R/T (related to) Dementia with sundowning with no resident specific identified behaviors to monitor for. The generic interventions listed include: Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. On 9/26/23 at 11:16 am, R10 began talking quickly with some mumbling and talking through her teeth and became anxious when talking about clothing that a family member had not yet brought in for her. On 9/27/23 at 8:45 am and on 9/28/23 at 9:40 am, R10 was sitting in her room in a wheelchair watching television with no behaviors, and on 9/28/23 at 9:40 am R10 smiled and waved at this writer. On 9/28/23 at 9:40 am, V14 LPN (Licensed Practical Nurse) stated (R10) will only holler out or yell if you disrupt her routine, otherwise she is good and doesn't exhibit any other behaviors. (R10) does not hit or have any physical behaviors, and is pleasant and cooperative as long as her routine stays the same and you don't enter her room in the morning until after she has opened the door. V14 LPN stated the only behaviors R10 exhibits is occasional hollering or yelling out. On 9/28/23 at 3:39 pm, V2 DON (Director of Nursing) confirmed there are no individualized identified targeted behaviors listed for R10, is unsure what behaviors R10 exhibits, and stated the CNA's (Certified Nursing Assistants) only document in the computer system if the resident has a behavior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 7 of 10 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 09/29/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which alerts the Nurse. At that same time, V2 stated the staff do not have an individualized resident centered behavior type tracking that they do each shift for (R10), and only document if a behavior occurs. On 9/28/23 at 4:00 pm, V3 ADON (Assistant Director of Nursing) stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R10 is receiving Quetiapine for Dementia with behavioral disturbances. When asked what the identified behaviors were for R10, V3 stated Dementia with sun downing. 2. The Order Summary Report for R20, dated 9/28/23, documents the following diagnoses: Dementia with behavioral disturbance, Mental Disorders due to known physiological condition, and PTSD (Post Traumatic Stress Disorder), and MDD (Major Depressive Disorder). This same Report documents a physician order on 9/11/23 as: Lorazepam 2 mg (milligrams), Give 1 tablet by mouth every 30 minutes as needed for seizures, if more than 3 doses are required contact hospice. The Order Summary Report does not list seizures as a current diagnosis for R20, or a stop date for the Lorazepam. The Order Summary Report for R20, dated 9/28/23, documents a generic generalized order Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting, etc. Interventions 1. Activities; 2. Change Position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 (one-on-one) every shift for Behavior Monitoring. Indicate number of behaviors per shift (use C for continuous). Indicate non-pharm (pharmacological) interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. The MAR (Medication Administration Record) for R20, dated July through September 2023, documents the same generic list of behaviors in R20's Order Summary Report: Monitor behaviors: Afraid/Panic, agitated, angry, anxiety, biting, crying, pacing, screaming/yelling, withdrawal, fighting, hallucinations, kicking, pinching, pulling lines, slapping/hitting, throwing objects, spitting etc. Interventions 1. Activities; 2. Change position; 3. Fluids; 4. Food; 5. Redirection; 6. Remove from environment; 7. Toilet; 8. 1:1 every shift for behavior monitoring. Indicate number of behaviors per shift. (Use C for continuous) Indicate non-[harm interventions used and outcome. Outcomes 1. Improved; 2. Same; 3. Worse. July through September MAR's all document no generic behaviors identified. There are no specific individualized targeted behaviors listed for R20 to be documented. The current Care Plan for R20 documents, date initiated 4/20/2022 Focus area as: (R20) Uses antianxiety medication as needed for end of life care, air hunger, restless and comfort. This plan of care does not mention R20 with seizure diagnosis, activity, or interventions related to seizures. On 9/26/23, 9/27/23, and 9/28/23 between the hours of 9:00 am through 4:00 pm, R20 was observed lying in bed with eyes closed, up in a reclining wheelchair, and covered with a blanket for breakfast and noon meals. R20 was fed by staff and taken back to his room and put back into bed. R20 did not exhibit any behaviors or seizure activity on these days. On 9/29/23 at 12:20 pm, V4 SSD (Social Service Directed) stated R20 had a seizure one evening that was pretty extensive and he was given medication for it that night. On 9/28/23 at 3:40 pm, V2 DON stated R20 had a seizure one evening and the doctor ordered Lorazepam for it and only gets the Lorazepam as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 8 of 10 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 09/29/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm On 9/28/23 at 4:00 pm, V3 ADON stated she does all the psychotropic medication tracking and monitoring for the residents. V3 stated R20 receives Lorazepam on a PRN (as needed) basis if he has a seizure, and confirmed there is no stop date for R20's Lorazepam order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 9 of 10 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 09/29/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the staff covered hair in a sanitary manner while in the kitchen. This failure has the potential to affect all 124 residents at the facility. Residents Affected - Many Findings include: The facility's Hair Restraints/Jewelry/Nail Polish/False Eyelashes Policy, Dated 2017, documents: Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. On 9/26/23 at 10:25am, V6 Dietary Manager was observed with staff in the facility kitchen. V6's hair on the back of her head was uncovered. V10 [NAME] and V11 [NAME] were preparing the facility's lunch meal for residents. V10 and V11 were observed to have hair uncovered on the sides and/or back of their heads. On 9/26/23 at 10:25am, V6 Dietary Manager and V10 [NAME] stated that for kitchen staff, all their hair was supposed to be covered. V6 stated, I have been running around a lot and it came out. On 9/27/23 at 2:05pm, V6 Dietary Manager stated: Anyone who enters the kitchen should have a hairnet on and staff should have all their hair covered when in the kitchen. The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 9/26/23, documents 124 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 10 of 10