Health inspection·September 28, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm guidelines that will aide in resident care and the prevention of nosocomial infections . 4. Bedridden, incontinent residents must be turned every 2 hours and inspected for fecal incontinence. 5. Residents must be cleaned after each episode of incontinence . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 2 of 19 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 09/28/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure physician ordered wound dressings were completed as ordered for 2 of 2 residents (R46, R47) reviewed for non-pressure wounds in the sample of 21. Residents Affected - Few The findings include: 1. R46's admission record shows she was admitted to the facility on [DATE]. R46's physician order sheet shows a 9/20/23 order to cleanse left lower leg with wound cleanser, apply xeroform to open blistered area on back of the left leg. Wrap with kerlix. Change daily and PRN (as needed), until healed. On 9/28/23 at 10:39 AM, R46 said her leg dressing does not get changed every day. V9 CNA (Certified Nursing Assistant) removed R46's sock to reveal a dressing dated 9/24/23. The September 2023 TAR (Treatment Administration Record) shows V15 LPN (Licensed Practical Nurse) documented R46's treatment as completed on 9/25/23, 9/26/23 and 9/27/23. The same record shows the daily dressing change was not completed on 9/20/23, 9/22/23 and 9/23/23. On 9/28/23 at 12:28 PM, V2 DON said the floor nurses should be completing the dressing daily when ordered. They do not need to date the dressing; it is not our policy. They can look at the TAR to see when it was last completed. They did not do the treatment; they should not be documenting it as completed. 2. R47's admission record shows he was admitted to the facility on [DATE]. His physician order summary report shows a 9/12/23 order to cleanse open areas on right lower extremity and the left lower extremity with wound cleanser, apply collagen sheet to wound bed, cover with calcium alginate with silver and ABD pad, wrap with kerlix and affix with tape daily and PRN if soiled or loose. R47's care plan documents he has a venous/stasis ulcer of the left lower leg and the distal right lower leg related to chronic venous insufficiency and edema. On 9/26/23 at 11:26 AM, R47 said his dressings do not get changed every day, it was not done yesterday. They seem to be short staffed here, so it doesn't get done. The September 2023 TAR shows the right and left wound dressings were 8/30/23. The right lower extremity dressing was not documented as completed on 9/2, 9/5, 9/8, 9/12, and 9/25/23. The left lower extremity dressing was not completed on 9/2, 9/12, and 9/25/23. On 9/28/23 at 10:49 AM V5 wound nurse said she works Tuesday through Saturday and when she is not in the facility, it is the responsibility of the floor nurses to ensure the wound dressing changes are completed. On 9/28/23 at 12:32, V2 said on the off days of the wound nurse, the floor nurses should be completing the dressing changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 3 of 19 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 09/28/2023 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 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** Based on observation, interview, and record review the facility failed to ensure pressure reduction interventions were in place and failed to identify and report skin changes for a resident at a high risk for pressure for one of nine residents (R78) reviewed for pressure in the sample of 21. Residents Affected - Few The findings include: R78's face sheet printed on 9/28/23 showed diagnosis including but not limited to history of sepsis, diabetes mellitus, hypertension, and urinary tract infection. R78's facility assessment dated [DATE] showed extensive staff assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene. The same assessment showed R78 is always incontinent of urine and bowel. The assessment showed two, stage 2 pressure ulcers present on admission. The assessment showed no severe cognitive impairment. R78's weekly wound summary assessment report dated 9/26/23 showed left lateral heel and right lateral heel stage 2 pressure ulcers. There were no other wound assessments on R78's body, other than the two heels. On 9/26/23 at 11:15 AM, R78 was lying in bed. Both of R78's heels were pressed up against the footboard of the bed. At 1:09 PM, R78's heels were still pressed up against the footboard. R78's private caregiver was in the room and assisted R78 to raise her heels. Reddened areas were present and both heels had clear, undated dressings on them. R78's caregiver rolled R78 to her side and an open, uncovered wound to her coccyx (upper buttocks) was observed. R78 was worried the open wound was laying in urine every time she is incontinent. The facility supplied pressure ulcer and non-pressure logs, both printed on 9/26/23 showed R78 had two, stage 2 pressure ulcer to both heels. There was no other wound documentation for R78 on the logs. R78's September 2023 physician order report showed an order start dated on 9/7/23 for Medi-boots (heel protector boots) to both feet while in bed. The same report showed an order start dated 9/7/23 for daily skin checks every evening shift for skin monitoring. On 9/27/23 at 12:43 PM, R78 was in bed lying on her back. Both heels were directly on the mattress and she was not wearing any heel protectors. R78 stated she has a sore on her buttocks for a couple of weeks now. R78 was not sure how or if it was being treated in any way. At 12:54 PM, V9 and V17 (CNAs-Certified Nurse Aides) entered the room and began to perform incontinence care. The CNAs confirmed R78 was not lying on any type of specialized air mattress used to reduce pressure. The CNAs confirmed R78 needs her heels floated to prevent them from touching the mattress. The aides said R78 already has pressure ulcers on her heels and more pressure will prevent them for healing. V17 went to R78's closet and a pair of green heel protectors were located on the bottom shelf. The aides pointed them out and left them in the closet. V9 and V17 rolled R78 to her side and removed the wet incontinence brief. Two red, open areas were observed on her buttocks near the right and left skin folds. Both were approximately one inch in length. There were no dressings on either area. V9 and V17 stated the areas have been there for about a week and a half. The aides said a barrier cream is the only thing currently being used on the areas. The aides stated V5 (Wound Care Nurse) checks on resident skin changes, and they were unsure if V5 had seen R78's buttock yet. V9 and V17 completed peri care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 4 of 19 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 09/28/2023 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 exited the room. Level of Harm - Minimal harm or potential for actual harm On 9/28/23 at 9:15 AM, R78's EMAR (electronic medical record) was again reviewed for any assessments or treatment orders for the open buttock areas. This surveyor was unable to locate any documentation in the EMAR. Residents Affected - Few On 9/28/23 at 10:08 AM, V5 (WCN) stated R78 likes to stay in bed a lot and she has blisters on both heels. V5 said her heels need to be floated or she should wear heel boots to help with healing. R78's heels need to be floated at all times when she is in bed. It is important to prevent further breakdown and to ensure the heels are not rubbing on the bed. V5 said R78 has orders for daily skin checks on the evening shift. It is a head-to-toe check done by the nurses. V5 stated the CNAs do skin checks with all cares, for example during hygiene and showers. V5 said aides should notify the floor nurse immediately after seeing any skin changes, within an hour or two. V5 stated she had no reports or knowledge of any skin issues with R78's back side. V5 stated wound need to be assessed and treatments begun to reduce the risk of infection and the decline of a wound. R78's wound reports dated 9/28/23 at 10:51 AM (after interview with V5) showed a left inner buttock wound measuring 1.80 cm x 1.20 cm x 0.10 cm (centimeters). A second report dated 9/28/23 at 10:41 AM, showed a right inner buttock wound measuring 0.80 cm x 1.2 cm x 0.10 cm. The facility's Prevention of Pressure Ulcers/Injuries policy dated 1/2019 states under the mobility/repositioning section: 10. When in bed every attempt should be made to 'float heels' (keep heels off the bed). The policy states under the general preventive measures section: 7. Immediately report any signs of a developing pressure ulcer to the supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 5 of 19 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 09/28/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen tanks were stored in a secure manner (R44, R78, R33) and failed to transfer a resident in a safe manner (R8) for four of four residents reviewed for falls in the sample of 21. The findings include: 1. On 9/26/23 at 9:58 AM, R44 was seated on the edge of his bed. A metal oxygen tank was in the corner near his bed. R44 was mentally confused and could not state why the tank was in his room. The tank was not secured in any manner. Oxygen tubing and a nasal cannula were attached to the tank. Both were undated and lying directly on the floor. At 11:56 AM, the tank was still unsecured in R44's room. On 9/26/23 at 11:15 AM, R78 was lying bed. An oxygen tank was near her bed, and it was not secured in any manner. Oxygen tubing and a nasal cannula were attached to the tank. Both were undated and lying directly on the floor. On 9/26/23 at 12:38 PM, R33 was lying in bed and V18 (Certified Nurse Aide) was providing peri care. An oxygen tank was near the head of the bed and was not secured in any manner. V18 stated she did not know why the metal tank was in her room and took it out after peri care. On 9/28/23 at 1:00 PM, V2 (Director of Nurses) stated oxygen tanks need to be stored correctly and securely. There should be a stable cart to hold the tanks when they are in resident rooms. Unsecured tanks have the risk of falling over and a high potential to combust. (R44, R78, and R33's September physician orders were reviewed with V2.) V2 stated, None of them have orders for oxygen. I have no idea why they are even in their rooms. The facility's Storage of Compressed Gas for Oxygen Use dated 5/2018 states under the fire risk section: Incorrect or careless use of oxygen equipment or use of materials not compatible with oxygen can cause a fire or explosion. The policy states under the safety guidelines section: Cylinders (tanks) must be secured at all times so they cannot fall. 2. R8's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include polyneuropathy, convulsions, hyperlipidemia, history of falling, weakness, abnormalities of gait and mobility, and age-related osteoporosis. R8's facility assessment dated [DATE] showed she has no cognitive impairment and requires extensive assistance from staff for transfers. R8's care plan initiated 4/12/16 showed, . has an ADL (Activity of Daily Living) self-care performance deficit related to complexities of medical diagnoses for example diagnoses of convulsions, weakness . Further risk related to history of R (right) lower extremity fracture and deconditioning. Impaired strength, endurance, balance, mobility, pain Toilet Use: The resident requires extensive assist of 1 staff for toileting. Transfer: The resident requires extensive assist of 1 staff to move between surfaces . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 6 of 19 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 09/28/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/26/23 at 11:06 AM, V17 CNA (Certified Nursing Assistant) assisted R8 from the wheelchair to toilet by pulling on the back of her pants. V17 did not use a gait belt. R8 said she needs one person to assist with transfers. R8 said the staff pull her up by the top of her pants or will use her arms. On 9/28/23 at 1:49 PM, V2 DON (Director of Nursing) said the facility requires gait belts be used when assisting residents with transfers. V2 said using the gait belt is for safety for both the residents and staff. The facility's policy with revision date of 3/2014 showed, Gait Belts, Policy: Direct care staff, CNAs, nurses, and therapist are required to use a gait belt when ambulating or transferring a resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 7 of 19 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 09/28/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R6's admission record shows she was admitted to the facility on [DATE]. The physician order summary sheet for September 2023 shows order dated 1/24/23 to change indwelling catheter bag every 14 days for infection control and hygiene. On 9/27/23 at 9:15 AM, R6 said the staff just empty the catheter bag and do not change it. R6's catheter drainage bag was observed to be dated 8/1/23. On 9/28/23 at 9:50 AM, V8 RN (Registered Nurse) said according to R6's orders, the drainage bag should be changed every 14 days, and said it appears the drainage bag is dated for 8/1. And the catheter should be changed every 30 days. The September 2023 TAR (Treatment Administration Record) shows orders to change the catheter drainage bag every 14 days. The TAR show it was not completed on 9/5 as ordered, and it was documented completed on 9/19/23. The order to change the catheter every 30 days was to be completed on 9/21/23, and it was not signed off as completed by nursing. On 9/28/23 at 12:34 PM, V2 said the nurse should be changing the bag and catheter as it is ordered. If the nurses are not completing the order, it should not be documented as completed. Based on observation, interview and record review the facility failed to ensure indwelling catheter care was performed in a manner to prevent cross contamination (R25) and failed to ensure an indwelling catheter was changed as ordered (R6) for two of two residents reviewed for catheters in the sample of 21. The findings include: 1. R25's face sheet printed on 9/28/23 showed diagnoses including but not limited to neuropathic bladder, retention of urine, and intellectual disabilities. R25's facility assessment dated [DATE] showed severe cognitive impairment and extensive staff assistance needed for bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R25 is always incontinent of urine and bowel. R25's September order summary report showed an order start dated 2/21/22 for an indwelling catheter for urinary retention. The same report showed enhanced barrier precautions initiated on 6/2/23 for catheter use. On 9/26/23 at 10:31 AM, R25 was lying in bed with a catheter bag hanging from the bed railing. A large orange sign was posted on her door that said: STOP ENHANCED BARRIER PRECAUTIONS. The sign clearly showed staff must wear gloves and a gown for high-contact resident care activities. The activities listed included providing hygiene and the use of a urinary catheter. On 9/27/23 at 1:16 PM, V16 (Certified Nurse Aide) gathered supplies and entered R25's room to perform catheter care. V16 wore gloves but did not don any gown. V16 unhooked the drainage bag from the bed rail and set it on top of the bedside table, well above the bladder. Cloudy urine was observed flowing backwards in the tubing. The urine was drained into a plastic urinal container that had dried (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 8 of 19 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 09/28/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yellowish-brownish urine all around the rim. V16 continued draining the bag while lowering it to the floor. The catheter tubing rested against the side of the urinal the entire time. V16 re-inserted the tube back into the bag and did not sanitize the tubing prior. V16 continued to wear the same gloves and cleansed R25's catheter tubing then rolled her to the side to cleanse her buttocks. V16 laid the unbagged, contaminated cloths on top of R25's bedside table. V16 placed a pillow behind R25, adjusted her blankets, and positioning wedge. V16 grabbed the dirty cloths and laid them on the roommate's bedside table while adjusting the roommate's linens. At no time did V16 change her contaminated gloves or wear a gown during catheter care. At 1:30 PM, V16 exited the room and this surveyor asked V16 about the sign on the room door. V16 stated, I think that is up there by mistake. She does not have any infection. I am guessing housekeeping put that up by mistake. She doesn't have any infections like MRSA or C-diff. Plus, there is not a PPE bin outside her room. I will ask though and see what is going on. V16 returned to the doorway less than one minute later with V13 (Registered Nurse). V13 said the enhanced barrier precautions signs are used for residents with certain devices like a foley catheter, feeding tube, or IVs. V13 said staff only need gloves in these rooms as extra precautions. Gowns are not a must. Gowns are only needed if the resident is on contact or droplet isolation. R25's care plan was reviewed and showed a focus area initiation dated 6/8/23 related to history of urinary tract infections and requires enhanced barrier precautions for foley catheter use. On 9/28/23 at 11:25 AM, V6 (Infection Control Preventionist) said all staff need a gown and gloves when providing high-contact direct resident care. An indwelling catheter is an example of a high contact care. V6 said catheter bags need to remain below the level of the bladder to prevent urine from flowing backwards into the bladder. Tubing needs to be sanitized prior to reinsertion back into the bag. Both can increase the risk of urinary tract infections. V6 said staff should know to use relatively clean containers for urine drainage. All contaminated peri care items should go directly into a bag. Gloves should be changed between all dirty and clean steps. Changing gloves after they become contaminated stops the spread of germs and urine. V6 said we just did a staff training about six months ago with the infectious disease doctor. Enhanced barrier precautions were fully explained and I thought all staff understood what they included. The facility's Enhanced Barrier Protection policy dated 5/2022 states: Healthcare providers must don a gown and gloves prior to entering a room and doff after leaving the room for high contact resident care activities. The policy listed high contact activities which included urinary catheters. The policy also stated: Make sure PPE, including gowns and gloves are available immediately outside of the resident room. Position a trash can inside the resident room and near the exit for discarding the PPE after removal . (R25 did not have a PPE bin outside of her room or a dirty isolation bin inside her room.) The facility's Urinary Catheter Care policy dated 3/2014 states: The primary purpose for giving daily urinary catheter care is to prevent infection. Maintain aseptic technique at all times when handling and caring for the catheter. The policy states: When emptying a drainage bag .the drainage spigot and the non-sterile container should never come in contact. Wipe the tip of the urine tubing with an alcohol wipe after emptying. The policy states: 20. Remove and discard gloves. 21. Clean and disinfect the bedside table or overbed table. The facility's Standard Precautions policy dated 1/2014 states under the gloves section: Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body part to another, when moving from a 'dirty' site to a 'clean' site. Remove gloves promptly after use, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 9 of 19 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 09/28/2023 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 0690 before touching non-contaminated items and environments surfaces and before going to another resident . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 10 of 19 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 09/28/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to change a PICC (Peripheral Inserted Central Catheter) line dressing for 1 of 1 residents (R6) reviewed for intravenous catheters in the sample of 21. Residents Affected - Few The findings include: R6's admission record shows she was admitted to the facility on [DATE]. The order summary sheet shows a 9/1/23 order to change the PICC line dressing every Sunday for infection control and hygiene. Use sterile technique. R6's September 2023 MAR (Medication Administration Record) shows the PICC line dressing change as completed on 9/24/23 by V19 RN (Registered Nurse). On 9/26/23, R6's PICC line dressing was observed to have a dated dressing of 9/20/23. On 9/28/23 at 10:04 AM V8 RN said PICC line dressing changes are done once a week, and must be completed by an RN, and the dressing is dated when changed. She said R6's dressing is dated for 9/20, and it should have been changed yesterday. On 9/28/23 at 12:33 PM, V2 DON (Director of Nursing) said the PICC line dressing should be changed weekly, R6's dressing should have been changed on 9/27/23. She said the nurses should not be documenting the dressing as completed if it is not done. The facility's 3/2014 policy for PICC line dressing changes documents General Guidelines 1. Change PICC line catheter dressing 24 hours after catheter insertion, every 7 days, or if it is wet, dirty, not intact, or compromised in any way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 11 of 19 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 09/28/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pain control for a resident with fractured ribs for 1 of 1 resident (R289) reviewed for pain. This failure resulted in R289 experiencing difficulty sleeping, difficulty participating in therapy and uncontrolled pain. Residents Affected - Few The findings include: R289's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple fractures of ribs, left side, need for assistance with personal care, abnormalities of gait and mobility, opioid dependence, spinal stenosis, low back pain, and intervertebral disc degeneration lumbar and lumbosacral region. R289's 9/20/23 Clinical admission note entered at 7:19 PM showed R289 reported an aching and radiating pain to left lower back at a 4 on the pain scale with the frequency of the pain being constant. R289's care plan initiated 9/21/23 showed, [R289] has acute/chronic pain related to disease process and multiple left rib fractures . [R289] will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date . Administer analgesia as per orders Evaluate the effectiveness of pain interventions per facility policy. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R289's September 2023 Physician Order Sheet showed R289 was admitted with an order for oxycodone-acetaminophen 10-325 (1 tablet) to be administered as needed every 4 hours for pain. R289's 9/20/23 admission Summary entered at 8:07 PM showed, Resident arrived to facility at 3:40 PM. Resident alert and oriented x 3 . Resident admitted to the facility for therapy due to a fall at home. Resident does complain of pain to left ribs due to multiple non-displaced fractures of the 6-10 ribs . On 9/28/23 at 10:29 AM, R289 said, Over the weekend, I think it was Sunday (9/24/23). I had pain in my shoulder and side. I have 6 broken ribs. I guess they didn't get my oxycodone from the pharmacy. Then last night at bedtime I asked for my pain medication and they said they didn't have it. They said there was not an order for the oxycodone so they gave me a muscle relaxer instead. I've been taking the oxycodone here so it didn't make sense. It was about 7-8 PM last night when I requested it for pain. I rated my pain at an 8 at that time. When I asked the nurse last night where the oxycodone was, she threw her hands up and walked out of my room. I didn't sleep last night so it was hard to do therapy this morning. I didn't sleep because I was in pain all night. On 9/28/23 at 11:07 AM, V8 RN (Registered Nurse) said R289 does have an order for oxycodone but she doesn't have any here (in the facility) currently. V8 said the sticker had been pulled so she believed it was reordered. V8 said the record showed it was last ordered on 9/28/23 (the day of this interview). V8 said the facility does have a supply of common medications from the pharmacy that she thought included oxycodone. At 1:28 PM, V8 said R289 still did not receive oxycodone. V8 said the NP (Nurse Practitioner) was in the facility today and said he had electronically sent in the prescription this morning. V8 said the NP was going to his office and was going to check and see what happened with the prescription. V8 said the nurses cannot take anything from the convenience supply without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 12 of 19 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 09/28/2023 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 0697 the prescription first so they were waiting for that. V8 confirmed R28 was still requesting the oxycodone at this time. V8 said, Well, she has broken ribs so of course she is requesting it Level of Harm - Actual harm Residents Affected - Few The facility's Controlled Drug Receipt/Record/Disposition Form for R289's supply of oxycodone showed a dose given on 9/24/23 at 5:48 AM was the last tablet of oxycodone available for R289 until the next pharmacy delivery. The facility's pharmacy requisition dated 9/24/23 at 9:09 PM showed R289's supply of oxycodone was received at the facility (16 hours after R289's last dose was administered). The facility's Controlled Drug Receipt/Record/Disposition Form for R289's supply of oxycodone received on 9/24/23 at 9:09 PM showed R289's supply of oxycodone was exhausted again on 9/27/23 at 11:03 AM. R289's September 2023 eMAR (electronic Medication Administration Record) showed R289's last dose of oxycodone was given on 9/27/23 at 11:02 AM (approximately 26 hours prior). On 9/28/23 at 1:49 PM, V2 DON (Director of Nursing) said, We typically reorder medications before they run out which is the goal. We have the [convenience supply] we can get medications out when that happens so we don't leave the resident without their medication. Sometimes we do need a new prescription. It is important to treat the resident's pain because it can cause a lot of other issues for the resident. The facility's policy and procedure revised 10/2020 showed, Pain Assessment and Management; Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management id defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 13 of 19 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 09/28/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review the facility failed to ensure sufficient staffing for all 86 residents residing in the facility. Residents Affected - Many The findings include: The facility's 9/28/23 federal 672 form for resident census and conditions of residents documents 86 residents residing in the facility. The same form shows none of the residents to be independent with ADL's (activities of daily living) for bathing, dressing, transferring, toilet use or eating. All residents are dependent on staff or require 1-2 staff for assistance. On 9/28/23 at 9:00 AM, V10 CNA (Certified Nursing Assistant) said she had worked in the facility since January. The staffing is usually 4 CNA's on each floor. When working with call offs there has been only 3 on the floor. V10 stated, with only 3 staff it is hard to get the mechanical lifts, getting all the residents out of bed, and get residents fed that need assistance. The call lights will take longer to answer, and showers sometimes must be rescheduled to second shift or the next day. V10 said at times staff are still trying to get people up after breakfast. On 9/28/23 at 9:43 AM, V11 CNA said now that some of the summer help has returned to school, there has been a shortage of staff. V11 said staff will stay over to cover the next shift or come in early. There have been as low as 2 aides on the floor. V11 stated, if there are only 2, no showers or charting is getting done, and we try to answer call lights as soon as possible. V11 said weekends are harder because there is no extra staff from the offices to help pass trays and answer call lights. On 9/28/23 at 11:20 AM, V9 CNA said today there are 5 staff on the floor because the state is here, but at times has had 2 aides on the floor. V9 said, When short on staff, we leave residents in bed and just change them, we try to get them done at least once a shift. There is no way to get the mechanical lift transfers because that requires 2 people, and scheduled showers will get bed baths, and call lights take longer. V9 said some residents maybe wait 1-2 hours but when there is no staff it is hard to get to call lights. V9 stated, Weekends are worse with call offs, that is the biggest issue. If residents stay in bed, they cannot do activities or get out of their rooms. V9 said on second shift, one of the CNA's has to take the smokers out, and that pulls away from the floor, leaving call lights unanswered and residents waiting to get into bed. On 9/27/23, R12 said the second shift is mostly short staffed. The call lights take too long to get answered. She said it took 3 hours to get assistance for the bathroom over the past weekend. She said there needs to be more staff on the day shift as well. Some days they do not get her out of bed until after 9:30 AM, and activities have already started. On 9/26/23 R42 said she can hear the staff talking about how short they are, and the aides tell her there is not enough help. She puts on her call light for assistance getting into the bathroom and must wait so long she had considered just transferring herself. She said in the morning it is over 30 minutes of waiting. R42 said the staffing is stretched. On 9/27/23 at 10:30 AM, during a resident group meeting, R59 said there is not enough staff. Lots of call offs, especially on the weekends, and there is no replacement, they just work short. R59 said, There's supposed to be 2 aides per hall but 1 to 2 CNAs call off most weekends. Nurses refuse to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 14 of 19 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 09/28/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many help out with aide tasks. R59 said there is long wait for call lights. R59 said he self-transfers at times because he gets tired of waiting. R59 said, We have mentioned staffing, call offs, and bad equipment repeatedly at monthly resident council meetings but nothing ever changes. And the smoking policy is dumb. Must have a staff member outside to smoke. It is 15-20 minutes for the CNA or activity aide to be off floor with smokers. Later in day activity aides are gone. We lose the much needed CNA on the floor to help, but they outside with smokers. That takes time away from caring for us. The resident council meeting minutes for June, July, August, and September 2023 each document concerns with call light response times and residents wanting CNA's from both halls to help. The September minutes show a request for increasing the CNA scheduling on the weekends. The June 6th minutes show too many call offs in groups and not enough on call staff to cover the hours. During the survey from 9/26/23 to 9/28/23, CNA's were observed on the floor answering call lights, assisting residents with ADL's, and passing meal trays. Each of the wings had 2 CNA's working, and each wing had a nurse. Multiple call lights were lit up throughout the day and were answered after varying amount of time, from 5 minutes to 20 minutes. On 9/28/23 at 8:18 AM, V2 DON (Director of Nursing) said V7 was completing the CNA schedules, but she is no longer in the facility. V2 said, The schedule is put out a month at a time and then there is a daily assignment sheet. That sheet will reflect call offs and open shifts. With a census of 86, there should be 8 CNA's in the building during first and second shifts. Four working on each floor. Over the night shift, there should be 2 on each floor. V2 said the facility has no agency aides, only in house CNA's. To cover the call off's the facility will offer bonuses and if no one picks it up then the managers come in and work on the floor. V2 said, When it gets down to 2 CNA's, a manager should come in. Do not recall if there has been only 2 CNA's working on the floor, since starting as the DON. It is the expectation for the nurses to be helping. The 1/5/2023 facility assessment staffing plan states: staffing adjustments are constantly changing and may by adjusted as census, resident's conditions, or acuity changes. The administrator will increase the staffing of other department staff to assist with resident needs. Nurse managers can be flexible in their schedules to assist on the floor as needed as can department managers. Agency staff is used to supplement facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 15 of 19 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 09/28/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a prescribed medication was available for administration for 1 of 1 resident (R289) reviewed for pharmacy services. The findings include: R289's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple fractures of ribs, left side, need for assistance with personal care, abnormalities of gait and mobility, opioid dependence, spinal stenosis, low back pain, and intervertebral disc degeneration lumbar and lumbosacral region. R289's 9/20/23 Clinical admission note entered at 7:19 PM showed R289 reported an aching and radiating pain to left lower back at a 4 on the pain scale with the frequency of the pain being constant. On 9/28/23 at 10:29 AM, R289 said, Over the weekend, I think it was Sunday (9/24/23) I had pain in my shoulder and side, I have 6 broken ribs. I guess they didn't get the oxycodone from the pharmacy .last night at bedtime (9/27/23) I asked for my pain medication and they said they didn't have it. They specifically said there wasn't an order for it but I've been taking it so it didn't make sense. That was at about 7-8 PM last night . they still don't have it. On 9/28/23 at 11:07 AM, V8 RN (Registered Nurse) said R289 has an order for oxycodone but she doesn't have any in the facility currently. V8 checked the electronic system and said R289's oxycodone was showing it was on order. On 9/28/23 at 1:49 PM, V2 DON (Director of Nursing) said, We typically reorder medications before they run out which is the goal. We have the [convenience supply] we can get medications out of when that happens so we don't leave the resident without their medications . The facility's policy and procedure with revision date of 06/2020 showed, Ordering Medications; Policy: Medications and related products are ordered from [pharmacy] on a timely basis. Procedure: 2. Refill orders are completed electronically through the MAR (Medication Administration Record) or the orders portal in [the electronic system], Reorder medication three days in advance of need to assure an adequate supply is on hand . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 16 of 19 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 09/28/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to follow their policy by not ensuring medications were stored properly for three of three residents (R288, R84, R20) reviewed for medication storage. The findings include: On 9/27/23 at 8:12 AM, V14 (LPN-Licensed Practical Nurse) was at the medication cart and prepared R288's morning medications. V14 opened the cart drawer and pulled out a clear bag containing two bottles of Amoxicillin-Pot Clavulanate (liquid antibiotic). Both bottles were labeled with open dates of 9/19 and expiration dates of 9/29. Directly above the dates were clearly marked labels stating, Shake well and keep in refrigerator. V14 dispensed the medication and put the antibiotic bottles back into the medication cart. On 9/27/23 at 8:49 AM, V15 (LPN) dispensed the morning medications for R28. V15 and this surveyor entered the room and R28's roommate (R84) was seated in a wheelchair. A bottle of prescription medication was directly next to R84 on the bedside table. The label showed it was an anti-fungal powder prescribed to a completely different resident. V15 said she had no idea how the powder got into the room. V15 said there is no reason it should have been left on the bedside table. On 9/27/23 at 8:01 AM, V13 (Registered Nurse) dispensed the morning medications for R20. V13 and this surveyor entered the room and R20 was lying in bed with his breakfast tray over him on the bedside table. Directly next to the meal tray was a box of prescription medication. The label showed it was an inhaler prescribed to a completely different resident. V13 stated he had no idea why the inhaler was in the room. V13 said, It should not be there because any resident could come by and take the medication. On 9/28/23 at 1:00 PM, V2 (Director of Nurses) stated medications requiring refrigeration can lose the ability to work correctly if they are not kept cool. V2 said refrigeration maintains the efficacy of the medication. The ability to fight infection is reduced when it is not stored correctly. V2 said resident medications should never be left unattended, especially ones not prescribed to them. There is the potential for them to go missing and not be available to treat them. The facility's Medication Storage in the Facility policy dated 6/29/21 states: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The policy further states: 11. Medications requiring 'refrigeration' or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 17 of 19 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 09/28/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was used in a manner to prevent cross contamination and failed to clean equipment after use in a contact isolation room (R33) and failed to cleanse a resident in a manner to prevent cross contamination (R13) for two of two residents reviewed for infection control in the sample of 21. Residents Affected - Few The findings include: 1. R33's September order summary report showed an order start dated 9/2/23 for: Contact isolation precautions related to MRSA (Methicillin Resistant Staphylococcus Aureus) and ESBL (Extended Spectrum Beta Lactamase) of the left leg wound every shift. On 9/26/23 at 10:37 AM, R33 was observed from the doorway and was lying in bed. A sign was posted on the door showing contact isolation and to see the nurse prior to entering. V13 (Registered Nurse) stated a mask, gown, and gloves were needed prior to entering the room.V13 stated R33 has poor circulation and a chronic venous wound to her left lower leg. V13 stated R33is on contact isolation for the leg infection and is seen weekly by the wound doctor. On 9/26/23 at 12:38 PM, V18 (Certified Nurse Aide) donned a gown, gloves and surgical mask and entered R33's room. R33 stated she was incontinent and needed to be changed. V18 rolled R33 to the side and cleaned her groin and buttock areas. V18 laid the unbagged, contaminated cloths on the pillow, next to R33's head. V18 continued to wear the same gloves and applied a barrier cream to R33's inner thighs which were red and irritated. R33 was rolled to the side again and began to have a bowel movement. V18 used toilet tissue to wipe away the BM then repositioned the bed pad and bed sheet. V18 wore the same gloves to adjust R33's pressure ulcer mattress controls and the power cord. V18 removed her gloves and gown then exited the room for more bed linens and towels. V18 and V13 (RN) returned to the room, both wearing gowns and gloves. V18 cleansed R33's buttocks again and used the same gloves to apply more barrier cream to the inflamed inner thighs. V18 then exited the room while still wearing the isolation gown and contaminated gloves. V18 got a red liner bag out of the PPE bin in the hall and pushed the mechanical lift into the room. R33 was transferred to her wheelchair while V18 still wore the contaminated gloves. At no time did V13 correct or prompt V18 to remove her contaminated PPE. V18 pulled dirty clothing out of the used isolation bin and bagged them in the red liner just obtained from the PPE bin. V18 stated the isolation bins should not be this full and she was unsure who was responsible for emptying them. V18 noticed R33's water humidification container was almost empty on the oxygen machine. V18 wore the same contaminated gloves to put more water into the container and hook it back up to the machine. V18 removed her gown and gloves and pushed the mechanical lift back into the hallway, without any type of sanitizing. On 9/28/23 at 11:25 AM, V6 (Infection Control Preventionist) stated gowns and gloves need to be removed before exiting a contact isolation room and gloves changed after peri care. Soiled linens need to be put in a bag as soon as they are used. Fresh gloves are needed when applying barrier creams to resident skin. V6 stated, It is important to change gloves and remove PPE in the room to prevent bacteria from spreading. There is the potential of urinary tract infections and the organism the resident is infected with can spread to others. All equipment used in contact isolation rooms should be thoroughly wiped down after use to stop the germs from spreading to other residents. The facility's Contact Precautions policy dated 5/22 states: During the course of providing care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 18 of 19 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 09/28/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm for residents, gloves will be changed after having contact with infective material that may contain high concentrations of microorganisms, (fecal material or wound drainage) . [NAME] gown upon entry into the room or cubicle. Remove gown and observed hand hygiene before leaving the resident-care environment .If common use of equipment for multiple residents is unavoidable, clean and disinfect such equipment before use on another resident. Residents Affected - Few 2. R13's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, peripheral vascular disease, bipolar disorder, morbid obesity due to excess calories, anxiety disorder, abnormalities of gait and mobility, and urinary incontinence. R13's facility assessment dated [DATE] showed she has no cognitive impairment, requires extensive assist of 2 staff members for most cares, and always incontinent of bladder. R13's care plan initiated 11/28/2019 showed, . ADL self-care performance deficit related to diagnoses of UTI (urinary tract infection), Diabetes, Bipolar disorder, obesity, weakness . Personal Hygiene Routine: Extensive, two staff assistance related to weakness and activity intolerance; Toilet Use: requires Extensive, two staff assistance related to weakness and activity intolerance . On 9/26/23 at 10:09 AM, V9 CNA (Certified Nursing Assistant) was providing care for R13. V9 applied gloves. V9 used a moistened towel and wiped under R13's abdominal fold. R13's abdominal fold was red and had a moist, white substance under it. V9 then used the same towel and wiped down the left and right side of R13's perineal area before folding the towel to an unused portion. V9 then wiped R13's buttocks and placed a new incontinence brief under her. V9 applied cream to R13's back and to a reddened area on the right side of R13's perineal area before removing her gloves. The same pair of gloves was worn for the entirety of R13's perineal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 19 of 19