Inspection·September 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few said, My leg hurts. I looked down and there was a lot of blood. I informed the agency nurse (V6). The nurse wrapped R1's wound and called an ambulance to have R1 sent out. V5 said after they looked at the side rail it did not have the little stoppers on the ends. V5 said, They had to pad the rails. Without the stoppers it is sharp. She was a little combative and did not want to get up, but I don't recall saying she was kicking. She moved one arm to say leave me alone and the other hand was holding onto the railing. It was literally only a couple minutes. At 9:48 AM, this surveyor went with V5 to look at R1's bed. V5 demonstrated how after she put a gait belt on R1, she put one hand behind her and put the other hand under her legs to turn R1. V5 said as soon as she brought R1's legs around to the side of the bed, R1 stopped talking, looked at V5 and said, My leg hurts. V5 said she looked down and saw a puddle of blood on the floor, so she laid R1 back down, placed her leg on a pillow, grabbed something to wipe the floor really quick so no one slipped on it, and then hurried to get the nurse. V5 said maintenance padded the rail and the bed frame after the incident. On 9/16/2025 at 9:51 AM, V8 (Maintenance Director) was on the hall R1 resides looking down at a sheet of paper. V8 said he was looking at the list showing rooms had side rails with no end caps on them when they did a building wide sweep to check all the side rails. V8 said there were several siderails didn't have the caps on. Eight on the 2nd floor and 15 on the 1st floor were missing the end caps on the side rails. V8 said he was double- checking all of them and would provide the list when done. V8 was asked to come to R1's room to remove the tape and pool noodle so this surveyor could see the end of side rail. Observed the end cap on the side rail at time. The metal bars on the end of the side rail were rough where the caps met the metal. V8 said he put end caps on after R1's incident and padded the rail and bed frame.On 9/16/2025 at 10:28 AM, V7 (Licensed Practical Nurse-LPN) said R1 can be very verbal at times with staff. Her skin is like paper. V7 said R1 had a history of skin tears.On 9/16/2025 at 11:06 AM, R1 was taken to her room for wound care. R1 said she does not remember how her injury happened. R1 said she thinks it is getting better. R1 was transferred from her wheelchair to her bed by V22 (certified occupational therapist-COTA) and V23 (Certified Nursing Assistant-CNA). R1 complained of back pain after sitting down on the side of the bed. Staff said they would let the nurse know. R1's right leg was right by the end of the railing where it was now padded and covered with black tape. V9 (Wound Nurse) did the dressing changes for R1. V9 said R1's staples were removed last week. V9 said we steri-stripped it, and it looks really good. R1 had an area on her right lateral leg was secured with multiple steri-strips. The area was curved (u-shaped). After completing the right leg dressing change. V9 removed the dressing from the left lower leg (shin area). R1 had a large, reddened area on the left leg with an opened area inside the red area. V9 said R1 had a laceration on area prior to getting the laceration on the right leg. V9 said the day before R1 got the laceration to her right leg, she was started on an antibiotic due to an infection in the left leg wound. During the wound care resident was alert and pleasant. No resistance to care observed. After wound care, resident was transferred back to her wheelchair and taken back to the dining room/activity area. On 9/16/2025 4:02 PM, V6 (Agency staff-LPN) said she worked 9/1/2025 on the overnight shift. V6 said at the end of her shift, the morning of 9/2/2025 an aide came to her and said she needed me to come with to R1's room. The aide said R1 had fluid coming from her leg. V6 said, I asked the aide what kind of fluid. She said blood. V6 said R1 was in her bed when she got to her room. Blood was on the sheet and a pillow. V6 said, The laceration was deep. I asked what happened and the aide said she did not know. It was a big gash. V6 said she told V4 (RN) oncoming nurse R1 needs to be sent out. He said call the doctor, family, and 911. R1 was sent to the hospital. V6 said V5 (CNA) did not say anything about R1 kicking or being resistant. V6 said, When I went in the resident did not seem upset or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 2 of 6 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 09/18/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resistive. V6 said V5 said she was getting R1 up and noticed fluid coming out of leg. On 9/17/2025 at 2:10 PM, V5 CNA said V1 (Administrator) and V3 (Regional VP of Clinical Operations) met with her right after she talked with this surveyor the previous day. V5 said they asked her what this surveyor was talking with her about, then they handed her a paper and said we forgot to have you sign the statement about what happened with R1's incident. V5 said she started reading it and was told to just sign it. V5 said she told them she was going to read it first. V5 said she told them she did not recall saying anything about R1 kicking. V5 said V1 and V3 said You did, just sign it. V5 said she told them R1 was not kicking, she just waved her hand and told me to go away because she did not want to get up. V5 said she felt pressured into signing the form and just signed it. V5 said as soon as she did, she regretted it, and wished she had not signed the statement.On 9/17/2025 at 2:57 PM, V2 (Director of Nursing-DON) said they determined something happened with the metal on the bed caused R1's injury. V2 said that is why her bed got padded. V2 said she expects staff to report any equipment might cause a safety issue for residents, and to take the equipment out of service until it can be repaired.On 9/18/2025 at 12:56 PM, V19 (R1's Physician/facility's Medical Director) said R1 is a very fragile individual. V19 said, She (R1) doesn't just get skin tears; she has skin explosions. V19 said there were not many days between the 9/2/2025 incident, and the one before. V19 said he would expect the facility staff to make sure the equipment used is smooth with no rough edges.The facility's investigation and QAPI plan for R1's 9/2/2025 incident showed R1 was sent to the hospital for a laceration to her right leg occurred while sitting the resident up on the side of her bed. R1 returned to the facility with 20 sutures. The list V8 had been going over showing side rails in which there were no end caps, or the end caps needed to be replaced showed over 20 side rails either did not have end caps, or they needed to be replaced. The facility's investigation file had staff interviews in it. V5's interview statement showed V5 said R1 was resistant and kicking her legs. V5's statement had a date up at the top of the form dated 9/2/2025. (These interviews were not provided to this surveyor until after V5 was interviewed by this surveyor). The facility's list of residents with wounds, provided on 9/16/2025 showed R1 has had 7 skin tears in the last three months. The facility's 9/16/2025 Wound Report for non-pressure wounds showed R1 had two active wounds as of 9/16/2025. One to her left lower leg in the front, from a previous incident on 8/25/2025 (facility was cited for this on annual survey), and one to her right lateral lower extremity measured 4.5 centimeters (cm) in length x 6.5 cm width. R1's Wound Assessment Details Report dated 9/11/2025 showed R1 sustained a laceration and was sent to the emergency room (ER). Staples dry and intact to site Resident with mild episodic pain to site. R1's 9/2/2025 notes from a local hospital showed New laceration of right lower extremity status post suture repair today. The facility's undated policy and procedure titled Supplies and Equipment, Environmental Services showed Equipment shall be monitored for good working condition or any needed repairs. Event ID: Facility ID: 145712 If continuation sheet Page 3 of 6 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 09/18/2025 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 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 interview and record review, the facility failed to ensure a resident's medications were available and administered as ordered for 1 of 3 residents (R4) reviewed for medications in the sample of 10.The findings include: On 9/17/2025 at 8:39 AM, V6 (R4's wife) said R4 did not get his medications for 3 days when he was first admitted to the facility. V6 said she was not sure what medications. V6 said R4 just told her he was not getting all his medications. V6 said the facility told them the hospital did not send them. V6 said, I could not go into the facility when he was first admitted because I had the flu. I told (R4) to say something about not getting all his medications. V6 said she knows she spoke to someone about the medications. V6 said, He is on a lot of medications. I was worried he was going to have withdrawal because he is on methadone. V6 could not identify who she spoke to at the facility regarding R4's medications. V6 said when R4 was discharged from the facility back to home, they did not give him a prescription for diuretics. Bumetanide. V6 said R4 was discharged on a Tuesday (9/9/2025). The home health nurse came on Thursday (9/11/2025), so he did not start taking the diuretic until Friday. V6 said R4 missed Wednesday and Thursday's diuretic.On 9/17/25 at 11:20 AM, V24 (Registered Nurse-RN) said she was the nurse on duty when R4 was admitted to the facility on [DATE]. V24 said she did some of R4's admission. Other nurses completed some of the assessments for his admission because it was near the end of her shift. V24 said there were medications that R4 missed due to the medications not being available. V24 said she marked in R4's medication administration record (MAR) on 8/12/2025 and 8/13/2025 that the methadone and Lyrica were not available. The methadone is used for pain. The Lyrica is also for pain. V24 said when a new resident is admitted to the facility, the nurse will fax a script (prescription) to the physician. The doctor signs the script and faxes it back to the facility, the nurse will fax it to the pharmacy, and the pharmacy will dispense it for delivery. V24 said it could take 24-48 hours on admit before we receive the medications. V24 said, We must have the script to dispense the medications. V24 said as soon as we fax the signed script to the pharmacy, we can request a code if we have that medication in the C-box medications. V24 said she was not sure if those are in the C-box. V24 said there were medications that the facility did not have available and R4 did miss some medications. At 11:38 AM, V24 said she was also the nurse that discharged R4 on 9/9/2025. V24 said, He discharged home with a multivitamin that he brought in and DuoNeb treatments. I asked (R4) if he needed any medications to take home, he said no just those two. Neither him, nor his wife (V6) asked for any prescriptions. I even offered to request scripts from the doctor, and he said no. (V6) was here when he was discharged . I went over the discharge instructions and showed them which medications we were sending with them. His wife asked me to write down when all his medications were last given and when they were due next.On 9/17/25 at 1:49 PM, V2 (Director of Nursing-DON) said the hospital did not send a script for methadone and Lyrica when R4 was admitted . V2 said, We were trying to find a doctor to get the script. V19 (R4's physician while in the facility, and the facility's Medical Director) was his physician on admission. (V19) ended up signing the script. Initially (V19) told the nurse to contact the hospital. The hospital would not sign the script, so (V19) ended up signing it. Methadone is used for pain, and R4 said he had been on it for 13 years. When I found out about his methadone not being available, I went to make sure he was not in withdrawal. He said he was not having any withdrawal symptoms but was concerned that he may start having them soon. That is when he told me he had been taking it for 13 years. At 2:36 PM, V2 said R4 was admitted on [DATE]. V2 said there was an order for methadone and Lyrica, but there were no signed scripts. V2 said if there is no script, the nurse should call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 4 of 6 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 09/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctor, and the pharmacy. If there are problems getting a script, then the nurse should call me. V2 said she was told the nurses reached out to V19, and the hospital, and was told the hospital would not send one to the facility because he was basically our problem. V2 said, Within one hour of speaking with (R4's) daughter and finding out about the medications not being available, I had the signed script sent to the pharmacy. V2 said then the facility had to wait for the pharmacy to deliver it. On 9/18/2025 at 1:56 PM, V19 (R4's physician while in facility/facility's Medical Director) he said he is familiar with R4. V19 said R4 is a challenging individual. V19 said the hospital should have sent 2-3 days' worth of the methadone with R4 on admission or sent a valid script with him. V19 said unfortunately, this is an ongoing issue with hospitals. V19 said the facility notified him to request the e-script (electronic script). V19 was not in a location where he could look it up on a computer to see when the facility first notified him of the needed e-scripts. V19 said the facility is usually pretty good at letting him know when they need one. V19 said R4 should have come to facility with the prescription, or the hospital should have let me know. V19 said they are not medications that the facility would probably have at the facility. V19 said the facility should have requested 2-3 days' worth of them from hospital.R4's August 2025 Medication Administration Record (MAR) showed an order for Pregabalin (Lyrica) 150 mg. Give 1 capsule two times a day for pain. The MAR showed four doses were not administered (8/11/25 at 8 PM, 8/12/25 at 8:00 AM, 8/12/25at 8:00 PM, and 8/13/25 at 8:00 AM). The MAR showed an order for Methadone Hydrochloride 5 mg. Give 1 tablet three times a day for pain. The MAR showed six doses were not administered as ordered. (8/11/25 at 9:00 PM, 8/12/25 at 8:00 AM, 12:00 PM, and 9:00 PM, and on 8/13/25 at 8:00 AM and 12:00 PM). R4's progress notes showed on 8/11/25, 8/12/25, and 8/13/25 the facility was awaiting delivery from pharmacy for the methadone. The 8/13/25 notes showed the facility was waiting on R1's Lyrica to be delivered from pharmacy. The 8/13/25 notes showed V2 (DON) documented at 3:38 PM that she received a call from R4's family regarding his missing medications. The notes showed the pharmacy informed her they had not received prescriptions from the doctor. 8/13/25 at 4:34 PM, V2 documented the pharmacy called and verified they received the prescriptions, and the medications would be delivered within four hours.R4's referral notes from the local hospital dated 8/10/2025 showed he was receiving methadone 5 mg three times daily and Lyrica 75 mg nightly in the hospital.The facility provided the pharmacy's packing slip showing the methadone and Lyrica were delivered to the facility on 8/13/2025 at 11:47 PM.The facility's policy and procedure titled Reconciliation of Medications, with a revision date of October 2018, showed, Gather the information needed to reconcile the medication list: a. Approved mediation reconciliation form. b. Discharge summary from referring facility. c. admission order sheet. d. All prescription and supplement information obtained from the resident/family during the medication history. e. Most recent electronic medication administration record, if this is a readmission. The policy showed, General Guidelines: 1. Medication reconciliation is the process of generating a master list of the resident's current medications. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician from the referring facility; c. Discuss with the resident or family; d. Contact the resident's primary physician in the community.Contact the admitting and/or attending physician . 7. Document findings and actions in the resident's electronic medical record. Documentation.If the discrepancy was unresolved, document how the discrepancy was communicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145712 If continuation sheet Page 5 of 6 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 09/18/2025 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 0755 to the charge nurse, physician, pharmacy, and/or next shift. 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 6 of 6