Inspection·June 12, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to apply devices to residents with physical limited mobility to 2 of 2 residents (R37, R61) reviewed for range of motion in the sample of 18. The findings include: 1. R37's Physician Order Sheet (POS) show R37 has diagnoses that include hemiplegia (paralysis) affecting right dominant side due to stroke. The same POS show an order of, Right resting hand splint to right hand. On after breakfast and off after supper daily. remove for grooming, and bathing and prn as needed. Monitor for redness /discomfort or skin changes. R37 also has an order of [R37] to wear sling when up in wheelchair to hold her right arm from falling down to side. On 6/10/24 at 12:36 pm, R37 was in the dining room for lunch. As soon as R37 saw this surveyor R37 used her left hand to lift her right hand showing this surveyor her contracted right hand. V12 Certified Nursing Assistant (CNA) who was with R37 said R37 should have a splint in her right hand. This surveyor asked R37 if she was referring to her hand splint and R37 nodded 06/11/24 at 9:30 AM, R37 was again in the dining room for activities. R37 again showed this surveyor her right hand, still, no splint or device to her right hand. V12 (CNA) said she has been looking for R37's splint since yesterday, she will check R37's drawer. At 10 AM, V6 (Restorative Nurse) said R37 has flaccid right hand and needs the splint and the sling to hold R37's right hand in place and prevent further decline. The facility policy entitled Application of Splints dated 1/3/24 show to properly apply a splint for support, comfort or aid in contracture prevention 2. R61's Physician Order Sheets (P.O.S.) dated June 2024 shows he is a [AGE] year old male with diagnoses including hemiplegia and hemiapresis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarct, hypertension, gout and chronic kidney disease. The P.O.S. shows orders for sling to arm when up in the chair. On 6/10/24 at 10:35 AM, R61 was lying in his bed. His left arm was bent upward resting on his chest. He said he can move his right hand, but can not move his left arm. There was no sling observed in his room. At 11:27 AM, V7 and V9 (Certified Nursing Assistant-CNA's) transferred R61 into his recliner chair and wheeled him in the dining room. V7 and V9 did not apply a sling to his left arm. On 6/11/24 at 1:49 PM, V5 (LPN) said R61 has limited mobility to his left arm, he can't move it too much. When he gets up in the chair he is supposed to wear a splint. On 6/11/24 at 2:00 PM, V6 (Restorative Nurse) said R61 has limited mobility to his left side and should have a sling in place when he is in the chair. R61's Restorative assessment dated [DATE] documents his left and right shoulder, right and left elbow, left and right hand/wrist, are within normal limits. The same assessment shows he is dependent on staff for bed mobility, transfers, toileting, personal hygiene and bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145621 If continuation sheet Page 2 of 4 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 06/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to ensure a residents prescribed medication was available to administer. This applies to 1 of 7 residents (R6) reviewed for pharmacy services in the sample of 18. The findings include: On 6/11/24 at 9:16 AM, V5 (Licensed Practical Nurse-LPN) during the morning medication pass, Did not administer R6's Depakote 500 mg (milligrams). She said she is out of R6's Depakote and will have to re-order the medication. V5 said she usually re-orders medications when there's about five pills left. If we tell the phamracy we need the medication STAT they will send it right away. R6's Medication Administration Record (MAR) dated June 2024 shows orders for Depakote ER oral tablet extended release give 500 mg two times a day at 9 AM and 5 PM. R6's MAR shows the Depakote was not administered on 6/11/24 (R6 missed two doses). On 6/12/24 at 9:17 AM, V2 (DON) said staff should check the medication convience box if they do not have the medications. V2 said she is not sure if Depakote is located in the convenience box. If the staff do not have the medication they should notify the physician and order the medication STAT thru pharmacy. V5 did not tell me yesterday R6 did not have her Depakote and confirmed Depakote is not located in thier conveinence box, V5 should have ordered the medication STAT. The facility's undated Medication Administration Guidelines Policy states If a medication with a current active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145621 If continuation sheet Page 3 of 4 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 06/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility failed to wash hands and change gloves in a manner to prevent cross contamination and failed to wear personal protective equipment (PPE) during care on a resident on enhanced barrier precaution to 2 of 18 residents (R8, R61) reviewed for infection control in the sample of 18. Residents Affected - Few The findings include: 1. On 06/11/24 at 9:20 AM, V10 (Certified Nursing Assistant-CNA) provided incontince care to R8. V10 removed R8's incontinent brief that was totally soaked with urine. R8 also had a large bowel movement. After providing incontince care and wearing the same soiled gloves and without performing handwashing V10 applied barrier cream to R8, applied new incontinent brief, turned R8 side to side, adjusted R8 in bed, applied new pants to R8 and pulled R8's privacy curtain. V10 then collected the soiled linens and left R8s' room still without removing her soiled gloves and without washing her hands. On 6/12/24 at 9 AM, V11 (Registered Nurse-RN) said staff should change their gloves and wash hands in between care. Once soiled gloves are removed, handwashing should follow to prevent cross contamination and spread of infection The facility policy entitled Hand hygiene/Handwashing dated 5/23 show, hand hygiene means cleaning your hands by handwashing (washing hands with soap and water). Hand hygiene will be performed after removing soiled gloves. 2. On 6/10/24 at 11:27 AM, a sign posted on R61's door for enhanced barrier precautions. R8 was laying in his bed with a gastric tube in place to his abdomen. V7 and V9 (Both Certified Nursing Assistant's) entered R8's room without donning a gown. V7 and V9 provided incontinence care, applied barrier cream, and transferred R8 from his bed to a recliner chair using a mechanical lift. On 6/12/24 at 9:15 AM, V8 (CNA) said staff should wear gown and gloves when providing direct care if a resident is on enhanced barrier precautions. R61's Physician Order Sheets dated June 2024 shows orders for enhanced barrier precautions related to presence of g-tube. The facility's Enhanced Barrier Precautions Policy dated 3/2025 states, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infections control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities high contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145621 If continuation sheet Page 4 of 4