Inspection·November 30, 2023

F 0689 diagnosis of a Bimalleolar ankle fracture, acute kidney injury and dehydration. Level of Harm - Actual harm Hospital records from a local community hospital dated 11/23/23 show that R1 presented to the emergency room for evaluation after a fall at the nursing facility. She complained of right hip and right ankle pain and was diagnosed with acute mildly displaced fractures of the medical and lateral malleoilli. Surgical intervention was not required. Residents Affected - Few On 11/30/23 at 8:35 AM, R1 said she is unable to recall the incident when she fell and doesn't recall a CNA in the bathroom with her. She said prior to her fall she could stand with staff help to get into her wheelchair and use the toilet, but now she cannot. On 11/30/23 at 8:48 AM, V4 (Restorative Nurse) said in the month or so prior to R1's recent fall she had been more depressed and slowed down due to the death of her husband. V4 said R1 has been a 1 person assist with a gait belt for toileting. V4 said gait belts should be used by all staff for resident transfers and ambulating. He said he does investigate resident falls to determine the cause but he has not yet spoken with V7 who is an agency CNA that was in the bathroom with R1 when she fell. V4 said he was told by the nurse on duty (V5) that V7 was cleaning stool off of R1's bottom and had turned away from R1 to get [NAME] wipes and R1 fell. On 11/30/23 at 9:20 AM, V7 (Agency CNA) said R1 had put the call light on in her bathroom and she went in to assist her. R1 had stool on her bottom and needed help to clean it off so V7 had R1 grab the bar on the wall in the bathroom and stand up. V7 said she was cleaning R1's bottom and needed more wipes so she turned away and left R1 standing by herself at the grab bar and went to the sink area in the bathroom and got more wipes. By the time she turned back around she saw R1, she was already falling and she saw R1's ankle twist. V7 said she was not aware that R1 was a fall risk and needed a 1 person touch assist and a gait belt for transfers. V7 said she believes to an extent had she used a gait belt it would have prevented R1's fall and had she known she was a fall risk and required a 1 person transfer assistance she would not have left her standing at the bar alone to get wipes she would have pulled the call light and gotten another staff person to assist her. On 11/30/23 at 9:27 AM, V5 (RN) said she was called to come to the bathroom by V7 because R1 had fallen in the bathroom. V5 said V7 told her that she was cleaning stool off of R1 and turned to get wipes and R1 fell. V5 said the facility protocol is for gait belts to always be used to assist residents to transfer and all staff should know to use them. V5 said since V7 was from agency maybe she didn't know to use one. On 11/30/23 at 9:33 AM, V3 (Medical Director and R1's physician) said he was out of town when R1 fell but his team was notified and followed R1 at the hospital. V3 said this type of ankle fracture is consistent with a fall. He said the CNA should have followed facility protocol and used a gait belt to assist R1 and he believes it could have helped the CNA prevent R1 from falling. On 11/30/23 at 10:45 AM, V11 (Physical Therapist) said R1 had a recent decline but was improving at the time of her fall. V11 said R1 required 1 person, a contact guard assist and the use of a gait belt for transfers. She said R1 should not have been left standing at the bar without support. On 11/30/23 at 11:01 AM, V2 (DON) said a gait belt is considered part of a staff uniform and V7 should have known to use it. V2 said she was not aware that V7 did not use a gait belt because she has not be able to get in touch with her until today. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145621 If continuation sheet Page 2 of 3 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 145621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Waukegan 2217 Washington Street Waukegan, IL 60085 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 0689 The facility provided and not dated, Gait Belt policy says that gait belts should be used by all staff and are used to prevent injury during transfers and ambulation. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145621 If continuation sheet Page 3 of 3