Inspection·April 2, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review the facility failed to identify fall risks and follow policy and procedures to prevent falls for two (R1 and R2) of three residents reviewed for falls in the sample of three. These failures resulted in R1 falling from wheelchair to the floor, bleeding, pain, bruising, and hospital visit with a diagnosis of nasal fracture and receiving sutures. These failures also resulted in repeat falls for R2. Findings include: The facility's undated Fall Management policy and procedure documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident and his or her family and staff regarding significant risks related to a resident's choice. Incorporating a resident's choices into the care plan, along with the family's and staff's input can help balance the interventions to reduce the risk of an accident, while honoring the resident's autonomy. This policy documents staff, family, roommate, and any other witness statements and Statements will be utilized as part of the root cause analysis. The facility's Accidents and Incidents policy and procedure, dated 5/2015, documents The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness and modifying interventions when necessary. Avoidable Accident means that an accident occurred because the facility failed to identify an environmental hazard or individual risk or the need for supervision and/or evaluate/analyze the hazard and risk and/or implement interventions consistent with the resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident and/or monitor the effectiveness of the interventions and modify the interventions as necessary in accordance with the current standards of practice. The facility's Resident Transfers and Safety Devices policy and procedures, dated 10/2017, documents All residents are assessed at time of admission for transfer ability. Residents who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during resident transfer. Transfers shall always be conducted following the principles of proper body mechanics, and safely. Each C.N.A. (Certified Nursing Assistant) must wear a (transfer) belt when transferring a resident. All resident falls and/or (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 145426 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 04/02/2025 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)