Health inspection·October 24, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide grooming assistance for one of three residents (R12) reviewed for activities of daily living assistance in a sample of 40. Residents Affected - Few Findings Include: The facility policy, ADL (Activities of Daily Living) Care, dated 11/2015 directs staff, To meet the grooming and hygiene needs of residents with dignity and privacy. Shaving: If the resident is a woman, shave only the areas with facial hair and apply moisturizer instead of aftershave. R12's current Physician Order Sheet, dated October 2024 documents the following diagnoses: Vascular Dementia, Osteoporosis, Cervical Spondylolysis, Polyosteoarthritis, Polymyalgia Rheumatica, Rheumatoid Arthritis and Weakness. R12's current Care Plan, dated 10/15/2024 includes the following Focus areas: (R12) has a deficit in ADL (Activities of Daily Living), physical mobility and requires staff moderate to total assistance from staff. (R12) has generalized weakness, impaired balance, strength and endurance. Also included are the following Interventions: Assist with dressing and grooming tasks. On 10/21/24 at 10:03 A.M., R12 was seated in a wheelchair in her room. 1/2-inch long facial hair was present to R12's entire chin. On 10/21/24 at 1:45 P.M., V2/Director of Nursing verified the presence of the chin hairs on R12 and that R12 should be shaved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 2 of 5 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 10/24/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. 3. R1's current medical record documents the following diagnoses: Difficulty in Walking; Primary Generalized Osteoarthritis; Muscle Weakness; Cachexia, and Neuralgia and Neuritis. Residents Affected - Some R1's Minimum Data Set Assessment (dated 09/16/24) Section GG, documents R1 has impairment of both sides to her lower extremities. On 10/21/24 at 09:37 AM, R1 was lying in bed covered with a blanket with her eyes closed. R1 appeared comfortable, and two 1/2 side rails were attached to R1's bed and were secured in the upright position. R1 stated she utilizes her bed rails to turn herself in bed. R1 then stated she prefers to spend most of her time in bed. On 10/22/24 at 12:35 PM, V12 (R1's son) stated R1 recently admitted under Hospice services. V12 stated his biggest concern is that R1, Needs to continue to receive consistent exercises to maintain her mobility. Especially in her legs. R1's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to BUE (bilateral upper extremities) and BLE (bilateral lower extremities), to be performed BID (twice daily). R1's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R1 did not receive range of motion exercises twice daily as ordered on 42 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R1's range of motion exercises have not been completed twice daily as indicated. 4. R6's medical record documents the following diagnosis: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. R6's Minimum Data Set Assessment (dated 09/30/24), Section C, documents a Brief Interview for Mental Status of 15, indicating R6 is cognitively intact. Section GG of this same assessment documents R6 has impairment of one side of her upper and lower extremities. R6's Restorative Program Note (dated 09/30/24) documents the following: Restorative Programs: Active Range of Motion, Splint/Brace Assistance, Dressing/Grooming. This same form documents, Splint/Brace Assistance: Carrot splint to be applied to left hand at rest, may remove during ADLs (activities of daily living), transfers and activities. R6's medical record documents the following restorative programming exercises are currently in place: Restorative AAROM (Active Assistive Range of Motion) program: To prevent limitations to be performed BID (twice daily) to RUE (right upper extremity) and BLE (bilateral lower extremities). R6's Monthly Restorative Documentation Report (dated 08/2024 - 10/2024) documents R6 did not receive range of motion exercises twice daily as ordered on 33 days during this time frame. On 10/23/24 at 12:50 PM, V2 (Director of Nursing) confirmed R6's range of motion exercises have not been completed twice daily as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 3 of 5 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 10/24/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/21/24 at 09:30 AM, R6 was reclined in her wheelchair watching television covered with a blanket. R6 was receiving oxygen at 3 liters via nasal cannula from an oxygen condenser and had a full mechanical lift sling in place underneath of her. R6's cell phone, call light and several personal items were within her reach. R6 stated she was recently sent to the hospital for my breathing and just returned to the facility and has been taking antibiotics since she returned. R6 stated her biggest concern is, the food is horrible. I don't have any teeth and they give me toast. R6 denied any other complaints at this time. R6's left wrist and hand was contracted, and the digits of her left hand appeared rigid and stiffened. No therapeutic appliance was in place at this time. On 10/23/24 at 01:05 PM, R6 was sitting in her wheelchair with her bedside table positioned in front of her eating a large salad. V10 (R6's Daughter) was sitting next to R6 assisting her with lunch. A washcloth was loosely in place in R6's left hand at this time. V10 stated, They never put the carrot in my hand. They forget and just stick a washcloth in it. V10 stated, She is rarely ever holding the carrot when I visit. R6 stated staff does not assist her with range of motion exercises twice daily, I try to exercise my (left) arm myself. R6 pointed out a carrot-shaped hand orthosis device that was sitting on a nearby dresser and stated, The carrot is sitting right over there. On 10/23/24 at 01:25 PM, V11 (Licensed Practical Nurse) confirmed R6 does not have her carrot splint in place and stated, It should be in place. Based on observation, interview, and record review the facility failed to ensure range of motion was implemented for a resident with functional limitations and failed to ensure an assistive device was in place for a resident with a contracture for four of four residents (R19, R38, R1 and R6) reviewed for range of motion in a sample of 40. Findings include: The facility's Range of Motion and Contractor Assessment and Preventions policy, dated 10/2019, documents that the objectives of range of motion exercise is to preserve resident's present range of motion. 1. R19's Restorative Program Note, dated 9/11/24, documents that R19 requires AAROM, active range of motion program, along with dressing and grooming. R19's Functional Abilities and Goals, dated 9/11/24, documents that R19's has an impairment to one side of her upper extremities. This form documents that R19 required substantial/maximal assistance for activities of daily living. On 10/24/24 at 10:15 AM, R19's Rehab/Restorative Assessment, dated 9/11/24, active assist range of motion-to prevent limitations, to be performed BID (twice daily) to bilateral upper and lower extremities. From 8/1/24 through 10/23/24 there were 43 times that R19's AAROM was not signed out as being completed. 2. R38's diagnosis include: Hemiplegia and hemiparesis, affecting the left non-dominate side. R38's Functional Abilities and Goals Assessment, dated 7/5/24, documents that R38 has an impairment to one side of her upper extremity. This form also documents that R38 requires substantial/maximal assistance for all cares. R38's Care Plan, dated 11/16/23, documents that R38's has a deficit in activities of daily living (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 4 of 5 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 10/24/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some abilities and requires staff assistance due to impaired mobility and weakness with left sided hemiplegia following recent cerebral infarction. R38 requires active range of motion programming at least twice daily by working each joint using extension, flexion, abduction, and adduction 10-15 repetition, do not pass the point of resistance. If pain is seen, stop activity immediately and notify the nurse. R38's Rehab/Restorative: Passive Range of Motion-To prevent limitations to be performed BID (twice daily) was not started until 10/15/24. R38's Range of motion was only completed 6 times from 10/15/24 through 10/23/24. R38's range of motion was not completed prior to 10/15/24 as documented in R38's care plan. On 10/23/24 at 1:45pm, V6 Restorative Nurse, stated that range of motion is to be completed twice daily. V6 stated that there are two restorative aides that do the range of motion during the week on day shift, but on the weekends the floor staff are to do the range of motion. V6 verified that if it is not signed out it is not being done. V6 stated that there are residents that refuse daily, so the staff will quit asking or attempting to do the range of motion. V6 verified that there is no documentation that either R19 or R38 refused range of motion. On 10/24/24 at 8:45am, V2, Director of Nursing stated that R38's range of motion was not started until 10/15/24. V2 also verified that since 10/15/24, R38's range of motion was not being done as care planned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145426 If continuation sheet Page 5 of 5