Health inspection·July 23, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many shower. On 7/23/25 at 10:21 AM, V8 Housekeeping Director stated R2's room should have been deep cleaned and his bed linen changed after R2's first Permethrin treatment and prior to him coming back to his room from his shower, but we are working on it. We haven't done it yet.3. R3's nurses note dated 7/19/25 showed R3 was found to have a petechial rash to his right upper and lower leg. The note showed, Clothes and linens washed. Room deep cleaned. R3's MAR dated 7/21/25 showed R3 received his first treatment of Permethrin Cream 5% (cream to treat scabies) topically for his rash. R3's physician order dated 7/22/25 showed R3 was placed on contact isolation for his rash (3 days after his rash was noted). On 7/23/25 at 8:45 AM, a contact isolation sign hung on the door to R3's room. A PPE cart was noted by R3's doorway. This surveyor donned PPE and entered R3's room. R3 was seated in a wheelchair by his bed. A red, pinpoint rash was noted to R3's left breast area and left arm. R3 stated he also had the rash to his bilateral inner thigh areas. R3 stated the rash to his left breast was still itchy. R3 stated to this surveyor, This is the first time seeing anyone in that garb (PPE). R3 stated he was put on isolation that morning (7/23/25), after he had eaten breakfast in the main dining room with other residents. R3 stated he'd had his first Permethrin treatment and shower, but no one had cleaned his room or changed his bedding in the last few days. On 7/23/25 at 8:51 AM, V5 and V6 CNAs stated R3 did eat breakfast in the main dining room that morning (7/23/25) despite staff knowing about R3's rash. V5 and V6 CNA each stated R3 was not put on isolation until the morning of 7/23/25. On 7/23/25 at 10:21 AM, V8 Housekeeping Director stated R3's room had yet to be deep cleaned, and his bedding had not been changed. On 7/23/25 at 10:51 AM, V15 LPN/Acting IP stated she had been the facility's Infection Preventionist for over a year but had yet to successfully complete the test for the infection preventionist course and receive the certification. V15 stated skin scrapings had not been done on R1-R3 or R7's rashes however they were assuming the rashes were scabies based on exposure and the appearance/symptoms associated with the rashes. V15 stated R1 was the first to develop a rash, on 7/3/25, that didn't seem to ever go away. V15 stated she believed R1-R3 and R7 had been exposed to an infectious rash by V6 CNA. V15 stated she was notified on 6/15/25 by an unnamed staff member, that on 6/10/25, V6 CNA was treated for a scabies-type rash by her physician. V15 stated she gave V6 CNA a verbal reprimand on 6/15/25 for not reporting her rash to administration and because she continued to work in the facility while having the rash. V15 stated V6 CNA provided cares to R1-R3 and R7 in June 2025 and July 2025. V15 stated staff are to place residents on contact isolation immediately once a suspicious rash is identified on a resident. V15 stated residents on contact isolation are not to come out of their rooms until their treatment is completed due the potential of spreading the rash to other residents. V15 stated, per facility policy, a resident's rash is to be treated with Permethrin cream, wait eight hours, and then shower the resident. This treatment is repeated seven days later. V15 stated, While the resident is in the shower, his/her room is to be deep cleaned, and all the bedding is to be changed. If that is not done and the resident comes back to a dirty room. This could potentially re-infect the resident with scabies. V15 stated she had not reported V6 CNA's or R1-R3, R7's skin rashes to the local health department. A facility Coaching/Corrective Action for Minor Offenses form dated 6/15/25 showed V6 CNA was given a documented verbal warning/training for a failure to disclose communicable disease in a timely manner or unreported. V6 CNA's June 2025 timecard showed V6 worked in the facility 6/4/25-6/9/25 and 6/11/25-6/13/25. The facility's Policy and Procedure Scabies dated 12/22/23 showed, Purpose: To identify and treat residents that have rashes that have the potential of being contagious. Residents that have been identified with a suspicious rash may be treatment prophylactically without confirmation testing and skin scrapings with medications ordered by the resident's attending physician. Initiate contact precautions upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 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 145712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 identification of the suspicious rash. Apply scabicide (Permethrin cream) to the skin. Allow the cream to sit on the skin following the MD orders. Re-shower the resident to wash off lotion. Terminally clean resident's room. Wash all linens, curtains, and soft items. Items that can be washed must be bagged and not used for 14 days. Repeat procedure in 7 days or according to MD order. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 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 145712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review the facility failed to employ an Infection Preventionist that had successfully tested and completed infection preventionist training and education. This failure has the potential to affect all 94 residents in the facility. The findings include:The Facility Data Sheet dated 7/23/25 showed a resident census of 94 residents. V15's Licensed Practical Nurse (LPN)/Acting Infection Preventionist (IP) Nursing Home Infection Preventionist Training Course records printed 7/23/25 showed V15 started the course on 9/30/2023 but had yet to successfully complete the test portion of the course and receive the certification. On 7/23/25 at 10:51 AM, V15 LPN/Acting IP stated she had been the facility's Infection Preventionist for over a year but had yet to successfully complete the test for the infection preventionist course and receive the certification. V15 stated she had been acting as the IP under the IP certification the previous Director of Nursing (DON) had but that DON no longer worked at the facility. On 7/23/25 at 11:57 AM, V1 Administrator stated the facility did not currently have a certified Infection Preventionist. The facility's Infection Preventionist job description (undated) showed the Infection Preventionist education and experience requirements included a certification in Infection Prevention. Event ID: Facility ID: 145712 If continuation sheet Page 4 of 4