Health inspection·October 30, 2024

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 monitor a resident during medication administration. This applies to 1 of 4 residents (R79) reviewed for pharmacy services in the sample of 19. The findings include: On 10/28/2024 at 9:43 AM, R79 was observed sitting up in her bed with medications sitting in a pill cup on her bedside table. R79 said the medications in the cup were her medications and she forgot to take them. R79 said the medications were left by the nurse about an hour prior. On 10/29/2024 at 9:11 AM, V3 Licensed Practical Nurse (LPN) said [R79] does not have a self-administration order for medications. V3 said she would not leave medications at the bedside for [R79]. V3 said the nurse should stay with a resident during medication administration because they could choke or drop a pill on the floor. On 10/30/2024 at 9:16 AM, V2 Director of Nursing (DON) said medications should not be left at the bedside and the nurse should make sure the resident takes the medications. R79's Order Summary Report dated 10/28/2024 does not list a self-administration order for medications. The facility's Administering Medications policy dated 11/2020, states . Residents may self-administer their own medication only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely and resident has successfully completed a competency for self-administration. Page 1 of 2 145712 145712 10/30/2024 Pavilion on Main Street, The 515 North Main Sandwich, IL 60548

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure staff wore beard coverings when serving food. This applies to 4 of 4 residents (R52, R70, R43, R80) reviewed for food sanitation in the sample of 19. The findings include: On 10/29/24 at 10:30 AM, during the resident council meeting hosted by this surveyor and attended by R52, R70, R43 and R80, a concern was brought up by residents that beard coverings are often not being worn when staff are serving food. On 10/29/24 at 12:23 PM, the noon meal was being served on the first floor. V5 (Cook) was scooping and plating the food from a portable serving table. The plates were then handed to V4 (Dietary Aide) to put on trays and add liquids and other food items before handing it to staff to serve to the residents on the first floor. V4 had a beard and mustache and did not have any face covering over his beard. At 12:30 PM the first floor service was over and V4 and V5 took the portable serving table up to the second floor to serve those residents. V5 verified that she and V4 had been together serving the entire first floor. At 12:34 PM, V4 and V5 were beginning the meal service for second floor. V4 still had no face covering on. At 12:38 PM, V7 (Dietary Aide) went up to V4 and told him he needed gloves and handed him a face mask which V4 then applied. On 10/29/24 at 1:47 PM, R52 said that V4 is the staff he was referring to who will not wear a beard covering when he is serving food. On 10/29/24 at 2:09 PM, V6 (Dietary Manager) said staff who have beards should be wearing at least a face mask to cover their facial hair when serving or plating food. V6 said some staff don't like the beard coverings the facility has so she is going to try and order new ones. R52, R70, R43 and R80's face sheets and dietary orders all show they reside on the first floor are served food from the facility kitchen. The facility provided Hair Restraints/jewelry/Nail Polish/False Eyelashes policy revised 2017 shows that food and nutrition employees should wear hair restraints and beard guards. 145712 Page 2 of 2