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. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145712 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 10/30/2024 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)