Inspection·May 17, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review the facility failed to identify and assess pressure ulcers on a diabetic resident's foot until they were Stage 3. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in a sample of 8. The findings include: R1's Physician's Order Sheet printed on 5/10/23 shows that R1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Cocaine Abuse, Hemiplegia and Hemiparesis, Anemia and Adult Failure to Thrive. R1's Specialty Physician Wound Evaluation and Management Summary dated 4/11/23 shows that R1 has a new Full Thickness, Stage 3 Pressure Wound on the left lateral foot. The wound measured 2 x 1.2 x 0.1cm with moderate serous exudate. This document states, Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater depth today. Diabetes is a relevant condition that affects wound healing and was considered. This same form shows that R1 has a second new full thickness wound on the left lateral ankle that measured 1.8 x 1 x 0.1 cm and had moderate serous exudate. The wound was 15% slough and 85% granulation tissue. A surgical excisional debridement procedure was performed (also on 4/11/23) to Remove Necrotic Tissue and Establish the Margins of Viable Tissue. The first facility assessment of these wounds are on the Skin Only Evaluation Form dated 4/12/23. The left lateral foot wound is documented as 2 x 1.2 x 0.1 Stage 3 pressure ulcers with moderate serous drainage. The left ankle wound is documented as a 1.8 x 1 x 0.1 cm Stage 3 pressure ulcer with moderate serous drainage. R1's Specialty Physician Wound Evaluation and Management Summary dated 4/25/23 shows that R1 has a new Full-Thickness, Stage 3 Pressure Wound on the right ankle. The wound measured 0.5 x 0.5 x 0.1cm with moderate serous exudate. The first facility assessment of this wound is on the Skin Only Evaluation Form dated 4/26/23. The wound is documented as a 0.5 x 0.5 x 0.5 x 0.1cm diabetic foot ulcer. The Treatment Administration Record dated April 2023 shows that a treatment order was initiated on 4/15/23(4 days after the wound was identified and assessed) for the left foot and left ankle and 4/27/23 (2 days after the wound was identified and assessed) for the right ankle. This same document shows that the facility has an order for daily skin checks for R1 on the day shift. On 5/10/23 at 3:30 PM, V2 (RN- Wound Nurse) stated, Since I am new and don't always know how to assess and categorize wounds. I thought I would just wait for him (V12 Wound MD) to come. I do daily skin assessments, and they are supposed to do them over the weekend too, but he (R1) is not easy to care for, especially when you have to remove his socks. On 5/11/23 at 10:30 AM, V12 (Wound MD) stated, Generally they tell me if a new wound is found on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 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 145712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion on Main Street, The 515 North Main Sandwich, IL 60548 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the resident and then I go in and assess it. I saw him (R1) previously a few months back and that wound healed, so I didn't see him again. When they presented him to me this time, he had developed several new pressure injuries. When I saw the wounds, I began to question his vascular issues. I made a referral to the vascular surgeon which I don't think he ever saw, and then he got septic and went on to be diagnosed with necrotizing fasciitis. If they found them early, they could have deteriorated to a Stage 3 by the time I saw him because I only come once a week. Event ID: Facility ID: 145712 If continuation sheet Page 3 of 3