Health inspection·December 18, 2023

F 0558 we run out. Level of Harm - Minimal harm or potential for actual harm On 12/11/23 at 12:23pm, surveyor inspected the (4th floor) long hall linen cart and there were no towels and/or washcloths available. Surveyor inquired about towel and washcloth availability on the unit. V11 (CNA) stated, They usually on this big cart (referring to the linen cart near the Nurses station) when they bring up the linen. Surveyor inquired where staff find towels or washcloths if unavailable on the unit. V11 responded, I usually go downstairs and see if they have any in the basement. Residents Affected - Many On 12/11/23 at 12:26pm, surveyor inspected the clean linen room for towels and washcloths with V10 (Laundry Aide). V10 stated, Right now I have one (1) towel, I'm waiting for them in the dryer. Surveyor inquired about washcloth availability. V10 responded, I don't have none right now they're in the dryer. Surveyor inquired how many towels and washcloths were sent to the units this morning. V10 replied, I count everything they (staff) take upstairs and referred to the laundry count sheets. The 12/11/23 count sheet affirms 1st floor had not received any linens. 2nd floor received 12 washcloths and 30 towels, 3rd floor received 14 washcloths and 25 towels, 4th floor received 5 washcloths and 25 towels. On 12/11/23 at 12:27pm, surveyor inquired about facility linen not in circulation. V12 (Laundry Aide) stated, The administrator orders the linen. On 12/11/23 at 12:31pm, surveyor requested to see the facility towels and washcloths not in circulation. V1 (Administrator) affirmed there were a dozen towels in each bag and there were 20 bags available therefore 240 total. V1 affirmed there were 60 washcloths in each bag, there were 3 bags and an open bag of 31 therefore 211 available. Surveyor inquired about the regulatory requirement for ensuring adequate linens are available for each resident. V1 stated, I believe it is like 3 and affirmed that 3 of each item (i.e: towels and washcloths) should be available for each resident. Surveyor requested the current facility census. V1 responded, 205 therefore 615 of each linen item should be available. The call light policy (revised 11/2013) states when the resident is in bed or confined to a chair be sure the call light is with easy reach of the resident. The (undated) laundry and bedding policy states linens are replaced as they become worn and in poor repair. Housekeeping manager will complete monthly audit to ensure that there is sufficient linen for resident use. Whenever linen need to be replaced, they are ordered through the linen vendor and rotated into the system. The (11/14/23) invoice affirms only 4 bath towels ($13.95 each) and 10 washcloths ($2.49 each) were ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 2 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based upon interview and record review the facility failed to implement the grievance policy and failed to investigate reported allegations for one of three residents (R1) reviewed for concerns. Residents Affected - Few Findings include: The 12/11/23 facility census includes 207 residents. On 11/13/23, IDPH (Illinois Department of Public Health) received allegations that R1 is not provided appropriate wound care and bed sores are deteriorating. The facility Social Worker is unavailable and not following up after several messages were left. On 12/12/23 at 1:09pm, the complainant stated A few weeks ago (mid-November 2023) he (R1) was complaining about having sores on his bottom, so I tried to call the facility to try to coordinate with the Social Worker there (facility) and wasn't able to get a hold of anyone. On 12/13/23 at 1:42pm, surveyor reviewed R1's (November 2023) social service progress notes however concerns were excluded. V18 (Social Service Director) affirmed a message was received from the complaint (regarding R1's care) and V2 (Director of Nursing) was allegedly informed however V2 affirmed that V18 did not relay any concerns regarding R1. On 12/13/23 at 2:09pm, surveyor inquired if someone calls the facility to speak with staff how does the call and/or message get relayed. V18 (Social Service Director) stated, They (receptionist) will transfer my call to the phone or they have to leave a message. Surveyor inquired if V18 received a voicemail and/or message regarding concerns with R1's care. V18 replied, No, I haven't. Surveyor inquired if a dialysis center staff left a message for V18 regarding concerns with R1's care. V18 responded, I heard that message about the dialysis, but I believe they (facility) already took care of that. I (V18) referred that to her (V2- DON/Director of Nursing) because it was all nursing concerns. Surveyor inquired what nursing concerns for R1 were reported. V18 replied, I do not recall, I guess um refer that to nursing. It's about dialysis. Surveyor inquired if V18 referred R1's concerns to V2 what concerns were relayed? V18 stated, I cannot recall. Surveyor inquired if R1's reported nursing concerns were documented in the progress notes and/or grievance form. V18 responded, I did not put that down. Surveyor inquired about the grievance process. V18 replied, When a family member come to me (V18) and give me a concern, I (V18) take care of the concern and I inform the Administrator about their concern. We (staff) do a grievance concern, and we investigate it. V18 subsequently reviewed the (November-December 2023) grievances for R1's reported nursing concerns - to no avail. On 12/13/23, V18 (Social Service Director) affirmed a message was received from the complaint (regarding R1's care) and V2 (Director of Nursing) was allegedly informed however V2 affirmed that V18 did not relay any concerns regarding R1. On 12/13/23 at 2:28pm, surveyor inquired if V18 relayed concerns regarding R1's wound care and/or deteriorating wounds (which were reported by dialysis staff). V2 (DON) stated, There's nothing that I can tell you about that. I never had any phone calls about that. The only concern that I received was regarding the dialysis and the fistula from the daughter. Surveyor inquired about the grievance process. V2 responded, As soon as I get a concern, I fill out a concern form and address what the issue is. I call right away the family and speak to them in regards to the questions they have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 3 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 0585 regarding care. Level of Harm - Minimal harm or potential for actual harm The filing grievances/complaints policy (revised 1/2017) states upon receipt of a grievance and/or complaint, social service will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 4 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based upon observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) care to two of three dependent residents (R3, R4) reviewed for ADL care. Residents Affected - Few Findings include: R4's diagnoses include dementia, lack of coordination, abnormalities of gait/mobility, and need for assistance with personal care. R4's (10/30.23) functional assessment affirms moderate assistance is required for dressing and maximal assistance is required for toileting. On 12/11/23 at 11:55am, R4 was somewhat covered with a sheet and completely naked. Surveyor inquired if R4 was dressed. V6 (CNA/Certified Nursing Assistant) removed R4's sheet and replied, He doesn't have on any clothes, he doesn't have nothing on. Surveyor inquired why R4 was not dressed. V6 stated, He says it be hot, so he doesn't wear them, he takes the clothes off however there were no clothes present. Surveyor observed a large bruise on R4's right arm and requested the assigned Nurse. V6 left the room (without assisting R4) and did not return. R4 sat up, put a pull-up on and walked to the doorway (undressed). On 12/11/23 at 12:02pm, V4 (LPN/Licensed Practical Nurse) entered the room and assisted R4 to the bathroom. V7 (CNA) affirmed she is assigned to R4. Surveyor inquired about R4's clothes. V7 stated, This morning I dressed him in a gown. Surveyor inquired where R4's gown was located V7 searched R4's bed and room however she was unable to locate a gown. V7 inquired where R4's gown was located R4 stated Yo no tengo V7 responded He said he doesn't have it no more, doesn't know where he put it. __ R3's diagnoses include dementia, abnormal posture, difficulty walking, generalized muscle weakness and need for assistance with personal care. R3's (9/20/23) functional assessment affirms (1 person) physical assist is required for toilet use. On 12/11/23 at 12:05pm, R3 was observed (in the dining room) seated in a wheelchair, leaning towards the left side, and appeared uncomfortable. At 12:10pm, surveyor inquired when R3 was placed in the wheelchair. V8 (CNA) stated, We got him up like at 7:30(am). Surveyor inquired if R3 is able to stand and/or turn/reposition himself. V8 responded, No, he's totally care. The left side of R3's pants appeared wet surveyor inquired when residents are supposed to be checked and/or changed. V8 replied, We're supposed to change em (residents) twice at least, at least sometimes three, it depends on their situation with their diaper. Surveyor inquired about the appearance of R3's pants. V8 stated, It's wet. V8 removed R3's brief which was moderately saturated with urine and contained a large bowel movement. V8 stated, He's wet and dirty. The (11/2015) ADL care policy states assist as needed with putting on clean undergarments, socks, and slacks. Next put on shirt, blouse, or dress. Finish with putting on shoes. The (03/2014) incontinence care policy states bedridden, incontinent residents must be turned every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 5 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 0677 2 hours and inspected for fecal incontinence. Residents must me cleaned after each episode of incontinence. 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: 145792 If continuation sheet Page 6 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 - Actual harm Based on observation, interview and record review the facility failed to provide timely incontinence care to prevent MASD (Moisture Associated Skin Damage), failed to document skin integrity impairment, failed to obtain timely treatment orders, and failed to offload wounds for one of three residents (R2) reviewed for pressure ulcers. These failures resulted in R2 incurring (facility acquired) stage 4 sacrum pressure ulcer (with bone exposed), osteomyelitis secondary to infection, fractured S5 vertebra - in the setting of osteomyelitis, pain rated 5/10, and severe sepsis. Residents Affected - Few The facility also failed to follow physician orders, failed to ensure that dressings were changed daily, failed to prevent MASD, and failed to offload wounds for R1. These failures resulted in R1 incurring a stage 4 sacrum wound with undermining (extensive damage beneath the skin surface). Findings include: On (11/27/23) IDPH (Illinois Department of Public Health) received allegations that R2 is being left in urine/feces contributing to wound development. R2 is not repositioned timely (> 2 hours). R2's dressing is not being changed on a consistent basis; on weekends the dressing is left soiled. R2 is complaining of back being broken. R2's diagnoses include dementia, mild protein-calorie malnutrition, type II diabetes mellitus, transient ischemic attack, and adult failure to thrive. R2's (11/2/23) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R2's (11/2/23) functional assessment affirms 1 to 2 staff are required for toileting, turning and repositioning. R2's (5/30/23) care plan states resident is at risk for pressure ulcer development related to impaired mobility, incontinence, and history of pressure ulcer. Intervention: Resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R2's (11/14/23) POS (Physician Order Sheets) include sacrum: clean with wound cleanser, apply medihoney, cover with foam dressing. Change daily and as needed. R2's progress notes include (11/13/23) dressing was changed, area above buttocks (exact location, wound description, wound stage, wound drainage, and/or wound measurements are excluded). (11/26/23) PRN (as needed) medication given 5/10 pain in buttocks. (11/29/23) Medical doctor ordered Levaquin (Antibiotic) 500 milligrams daily for 10 days due to elevated white blood cell count. (12/1/23) Resident's wound observed with a foul smell during dressing. Doctor ordered to send resident to hospital for wound evaluation. Resident admitted for sepsis at hospital. On 12/18/23, surveyor requested R2's initial wound assessment and the wound assessment prior to (12/1/23) hospital transfer. Surveyor received R2's (11/16/23) wound assessment which affirms (facility acquired) MASD. Classification: incontinence. Date identified: 11/16/23 however the (11/13/23) progress note affirms a wound was present 3 days prior. R2's (11/29/23) sacrum wound assessment affirms pressure ulceration (stage 4). Wound deteriorated, increased in size, undermining present. Peri wound with dark discoloration, mild odor present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 7 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 R2's (November 2023) TAR (Treatment Administration Record) affirms sacrum treatments were documented 11/14/23 (2 days prior to initial wound assessment). Level of Harm - Actual harm Residents Affected - Few R2's (12/1/23) history & physical states patient presents to the emergency department for sacral wound evaluation from the nursing home. [NAME] blood cell count 12.1 (High). Patient appears to have infected sacral wound, concern for underlying osteomyelitis. Sacral wound with exposed muscle. Pelvis CT (Computed Tomography) with signs of acute osteomyelitis. Fracture at S5 vertebra cannot exclude pathologic fracture - in the setting of osteomyelitis. Sacral decubitus ulcer coursing to the coccyx and inferior most sacrum. Of note a portion of the skin ulceration tunnels within the subcutaneous fat approximately 3 centimeters superiorly posterior to the upper coccyx and lower sacrum. There are some thin fluids within the ulceration and adjacent edema/cellulitis. Diagnosis: Severe sepsis. Sacral ulcer acute. Sacral osteomyelitis acute. On 12/18/23 at 11:17am, surveyor inquired about R2's (11/13/23) dressing change which was documented in the progress notes. V22 (Licensed Practical Nurse) stated, The CNA (Certified Nursing Assistant) told me the dressing was coming off and asked me to change it. She (R2) had a wet to dry (dressing) already on, I just put a new bandage back on. Surveyor inquired if R2 had treatment orders (on 11/13/23). V22 responded, We don't need orders for a wet to dry dressing. Surveyor inquired about the appearance of R2's (11/13/23) wound. V22 replied, I don't remember. On 12/18/23 at 12:24pm, surveyor inquired if physician orders are required for wound treatments. V15 (Wound Care Nurse) stated, A physician order is always required for wound treatment, for all wound treatment we do require physician order. Surveyor inquired when R2's skin integrity impairment was identified. V15 reviewed the electronic records and responded, On November 13 it was an area of moisture skin damage and then on the 16 it deteriorated and became stage 2 pressure sore. Before she was sent out (12/1/23) it was debrided by wound care doctor and stage 4. Surveyor inquired what causes MASD. V15 replied, Contact with urine is moisture. She (R2) had a very fragile skin, and she is incontinent. Surveyor inquired what causes dark discoloration of the peri wound. V15 stated, Pressure. Surveyor inquired what causes a stage 4 wound. V15 responded, Pressure and moisture all together plus not just that also different factors; it's a process of repositioning and history of pressure ulcer that also contributing to stage 4. Surveyor inquired what causes undermining. V15 replied, Pressure, in her (R2) case undermining was created when doctor debrided the wound. Pressure, plus moisture, plus the wound itself all together that's how her (R2) wound developed. Surveyor inquired what an odorous wound is indicative of. V15 stated, Infection. Surveyor inquired what causes osteomyelitis. V15 responded, Infection of the bone. Surveyor inquired about the appearance of R2's wound prior to 12/1/23 hospital transfer. V15 stated, It was deep, it was all the way up to the bone after debridement. __ On 11/13/23, IDPH (Illinois Department of Public Health) received allegations that R1 is not provided appropriate wound care and bed sores are deteriorating. R1's diagnoses include dementia, type II diabetes mellitus, end stage renal disease, dependence on dialysis, and pressure ulcer. R1's (11/1/23) BIMS determined a score of 5 (severe impairment). R1's (11/1/23) functional assessment affirms resident requires maximal assistance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 8 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 turning/repositioning and 1-2 person assist with toileting. Upper extremity impairment (one side) and lower extremity impairment (both sides) was also noted. Level of Harm - Actual harm Residents Affected - Few R1's care plan includes (10/17/23) resident is at risk for pressure ulcer development related to immobility, incontinence, type II diabetes mellitus, and failure to thrive. (11/20/23) readmitted with unstageable (coccyx/left buttock) pressure ulcers. R1's POS includes (11/20/23) skin check every shift. Turn and reposition in bed every 2 hours and as needed. Utilize foam wedges or pillow to offload pressure areas. Apply zinc oxide cream to buttocks, sacrum and perineal area every shift after incontinence care. (11/29/23) Sacrum: clean with wound cleanser, apply medihoney, pack open areas with calcium alginate, cover with foam dressing. Change daily and as needed. R1's (11/20/23) wound assessments include the following (present on admission) coccyx (unstageable) pressure ulceration. Tissue types: 40% epithelial, 15% bright pink, 45% slough loosely adherent. 4.5 x 2.5 x 0.2cm (centimeters). Left buttock (unstageable) pressure ulceration. Tissue type: slough loosely adherent 100%. 2.5 x 2.0 x 0.2cm. R1's (11/30/23) wound assessment states pressure ulcer at coccyx and left buttock are connected with undermining and therefore recalcified by wound care nurse practitioner as one wound with location at sacrum. R1's (12/7/23) sacrum wound assessment states (stage 4). Tissue types: bright beefy red 80%, slough loosely adherent 20%. 6.0 x 5.0 x 2.0cm (increased in size). On 12/12/23 at 2:07pm, R1 was lying in bed and on his back therefore the sacral wound was not off loaded. Surveyor inquired about R1's wounds. V5 (Licensed Practical Nurse) responded, I know the wound care nurse (V15) just changed his dressings and his pouch (re: colostomy) about 10, 15 minutes ago. V16 (Family) at bedside also affirmed R1's dressing was just changed. V5 removed R1's incontinence brief (as requested) and his right hip was covered with a red rash. V5 stated, He's got a rash and it's probably from the diaper, it's too tight or if it's not changed often. A (4 x 4) border dressing (dated 12/12) observed on R1's sacrum appeared clean, dry and intact. V5 removed R1's border dressing (as requested) the small open area (between the buttocks) had no treatments and/or dressing atop of the wound. The large open area on R1's right buttock appeared to be packed with a dressing however the dressing (outside the wound) had dried sangeunous drainage and was adhered to R1's skin. Surveyor inquired if the dressing packed in R1's wound appeared as if it was just changed. V5 stated, No, the dressing says 12/12 but it doesn't seem like it. It shouldn't be dry; it should be fresh. If it's open or tunneling (referring to the wounds) it should be honey or something like that and it looks dry. Surveyor inquired if a dry dressing promotes wound healing. V5 stated, No, it has no purpose. On 12/12/23 at 2:20pm, surveyor inquired about R1's treatment orders. V15 (Wound Care Nurse) stated, He has daily medihoney, calcium alginate and a dry dressing. Every morning calcium alginate and medihoney goes directly to the wound bed. Medihoney and/or zinc oxide were not present on R1's skin and or inside the border dressing. Surveyor requested to see R1's treatments. V15 responded, We don't keep them separately; we have a house supply that we use. V15 opened the treatment cart and presented wound cleanser (with R1's name), border dressings and calcium alginate. Surveyor inquired where R1's medihoney was located. V15 replied, Medihoney? I used the last, it was just a little bit left. So now Im gonna open a new one however medihoney was not available on the treatment cart at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 9 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 R1's (December 2023) TAR (Treatment Administration Record) affirms on Saturday (12/9/23) (daily) sacrum treatments were not documented. Level of Harm - Actual harm Residents Affected - Few On 12/14/23 at 2:34pm, surveyor relayed concerns regarding facility staff not following treatment orders and/or changing dressings daily as ordered. V21 (Medical Director) stated, Nursing have to take care of the patients, they have to do a better job. Surveyor inquired about potential harm to resident wounds if treatments are not followed and/or not administered daily (as ordered). V21 responded, It can get infected and make it worse. The prevention of pressure ulcer policy (revised 1/2019) states; assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly for the first 4 weeks, then quarterly and upon any changes in condition. CNA's will inspect the skin on a daily basis when performing or assisting with personal care or ADL's. Select appropriate pressure reducing support surfaces based on resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Evaluate, report and document potential changes in the skin. If the resident refused the care, document the reason why and notify the supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 10 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure (R3's) functional assessment was accurate, failed to ensure staff use proper and/or appropriate transfer techniques, failed to implement and/or revise fall care plan interventions, failed to provide supervision, and failed to obtain a timely x-ray for one of three residents (R3) reviewed for falls/IOUO (Injuries of Unknown Origin). These failures resulted in R3 sustaining acute fractures of the left lateral 7th through 9th ribs (identified 12/2/23) and pain rated 3/10. The facility also failed to implement the falls management policy, failed to document (R4's) fall, failed to notify (R4's) family/physician immediately and failed to conduct daily skin assessments. These failures resulted in R4 sustaining a large bruise to the right arm (identified 12/11/23 - by the State surveyor). Findings include: R3's diagnoses include dementia, abnormal posture, difficulty walking, transient ischemic attack, and generalized muscle weakness. The fall log affirms R3 fell on 7/27/23 and 11/12/23. R3's (11/12/23) incident report states informed by CNA (Certified Nursing Assistant) that resident was on the floor. Resident observed lying on the floor next to his bed with feces and urine. Resident has right side weakness due to previous stroke. No witnesses found. [R3's November 2023 pain assessments affirm pain level was rated 0 post fall]. R3's progress notes state (11/30/23) staff reported resident was unable to get up this morning due to painful area on his abdomen and chest on left side. Nurse Practitioner made aware, order chest x-ray. [Nothing was documented 11/23/23 through 11/29/23]. (12/2/23) Writer received call from hospital, resident has left lateral acute fracture on ribs 7, 8, and 9. (12/3/23) Resident noted with facial grimacing when care was being provided. PRN (as needed) medication was provided. (12/5/23) Resident noted with facial grimacing when care was being provided. PRN medication was provided. R3's (December 2023) pain assessments affirm pain level was rated 2-3. R3's (12/2/23) history & physical states patient presents to the emergency department for evaluation of a possible fall. Per EMS (Emergency Medical Service) as well as by patient, patient fell about a week ago last Saturday (11/25/23) when he was walking, lost his balance, fell towards the side and hit a table, landing over the table with his (left) side rib cage. Patient has more pain over the left side when he moves. Mild tenderness over the right lower rib cage. Worst tenderness over the left mid clavicular line lower ribcage as well as mid-axillary line. Tenderness over torso. He had too much pain with doing x-rays, given Fentanyl (Schedule II Narcotic) afterwards. On 12/13/23 at 9:51am, surveyor inquired about R3's rib fractures (identified 12/2/23). V1 (Administrator) stated, I believe he might have had an unwitnessed fall and maybe fell on the table. On 12/13/23 at 12:03pm, surveyor inquired about R3's (11/30/23) change in condition. V17 (Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 11 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 Practical Nurse) stated, Staff reported to me that he was uncomfortable and then I went to see him (R3). I asked him (R3) you in pain? He said I don't know but he look uncomfortable and maybe were in pain. At that moment the Nurse Practitioner was there, and I can see he (R3) was no good and did not want to get up. He (Nurse Practitioner) order x-ray for the abdomen, chest and hip. I (V17) placed the order that day but I think it was the next day that they come and do the x-ray. Surveyor inquired if the x-rays were ordered STAT (on 11/30/23). V17 responded, Yes. Surveyor inquired about STAT turnaround time. V17 replied, Normally we call and say to the technician this is stat and they (technician) say we will be there as soon as possible they don't give the hour or anything like that. I remember I was calling to the x-ray and they don't answer two times. Surveyor inquired how R3 incurred an injury. V17 stated, He didn't tell me any because he doesn't look like he want to answer me. Surveyor inquired about R3's functional status. V17 responded, That day he was in a (Brand Name wheelchair) when I went to see him. They (Staff) told me he (R3) is not too stable they use a 2 or 3 people to get in the (Brand Name wheelchair). On 12/14/23 at 2:27pm, surveyor inquired about potential harm to a resident that has an unwitnessed fall. V21 (Medical Director) stated, To my knowledge we (facility staff) always report any fall and for any unwitnessed fall. We always send the patient to the emergency room for evaluation. They (residents) can have a broken bone, or they can have a bleeding in the head (a hematoma) so we always send them out. R3's (12/2/23) x-ray (obtained 2 days after pain was noted) affirms acute fractures of the left lateral 7th through 9th ribs. R3's (9/20/23) BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). R3's (9/20/23) functional assessment states (1 person) physical assist is required for bed mobility and transfers however observation and interviews were incongruent with this assessment. R3's (12/15/22) care plan states resident is at risk of falls related to dementia, weakness, and history of falling. Interventions: one side rail placed for bed mobility and transfers. Educate on safe transfer technique, assist to bathroom as needed. Resident is able to toilet himself with one person assist. Monitor/report any changes (re: declines in function). On 12/11/23 at 12:05pm, R3 was observed (in the dining room) seated in a wheelchair, leaning towards the left side, and appeared uncomfortable. On 12/11/23 at 12:10pm, surveyor inquired when R3 was placed in the wheelchair. V8 (CNA) stated, We got him up like at 7:30(am), it took four of us (staff) to transfer him to the chair. Surveyor requested to inspect R3's incontinence brief. V7 (CNA) and V8 placed a gait belt on R3 (R3 has fractured ribs) and instructed him to stand however he (R3) was unable to do so. R3 was lifted from the chair and stated, Don't let me slip as his feet were sliding sideways on the floor. V7 and V8 proceeded to transfer R3 (instead of placing him back in the chair) and almost dropped him on the floor however his butt landed on the mattress (near the floor). R3 has a low bed made of PVC pipes which is unable to be raised and/or lowered to accommodate resident and/or staff during transfer. [R3's bed did not have side rails for bed mobility and/or transfers as stated on the care plan]. Surveyor inquired if R3 can walk. V8 stated, When I first started around 6 or 7 months ago but not now. You see we have difficulty at him holding up. Surveyor inquired if R3 is able to stand. V8 stated, No. Surveyor inquired if R3 is able to turn and/or reposition himself. V8 stated, No, he's totally care. V8 removed R3's brief which was moderately saturated with urine and contained a large bowel movement. V8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 12 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 stated, He's wet and dirty. Level of Harm - Actual harm R3's (12/7/23) care plan states resident has fracture of multiple ribs of left side however supervision and/or additional fall prevention interventions (re: mechanical lift) are excluded. Residents Affected - Few The accidents and incidents policy (revised 5/2015) states adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. A systematic approach has been put in place to promote resident safety and reduce accident/incidents. This approach includes identification of hazards, implementation of interventions, and supervision. __ R4's diagnoses include dementia, lack of coordination, abnormalities of gait/mobility, and need for assistance with personal care. R4's (10/30.23) functional assessment affirms moderate assistance is required for dressing and maximal assistance is required for toileting. R4's (10/25/23) care plan states resident is at risk for falls related to history of falls, restlessness, and agitation. Interventions: be sure resident's call light is within reach. Ensure that resident is wearing appropriate footwear when ambulating. On 12/11/23 at 11:55am, R4 was lying in bed however the call light was on the floor and out of reach. Surveyor inquired about the location of R4's call light. V6 (CNA) stated, It's by the bed on the floor. Surveyor inquired if R4 could reach the call light. V6 responded, Not from this angle he couldn't. Surveyor observed a large bruise on R4's right arm and requested the assigned Nurse. V6 left the room (without assisting R4) and did not return. R4 sat up, put a pull-up on and walked (with slow, shuffled, unsteady gait) to the doorway (without socks and/or shoes). On 12/11/23 at 12:02pm, V4 (LPN/Licensed Practical Nurse) entered the room and assisted R4 to the bathroom. Surveyor inquired about the bruise on R4's arm. V4 responded, With the shoulder? He (R4) has a bruise over there, let me see and assessed the resident. Surveyor inquired how R4 sustained the bruise. V4 replied, I just came back from vacation and affirmed she was unsure. V4 accessed R4's EMR (Electronic Medical Records) and stated, There is no incident there, I don't see any incident put in risk management if we saw something like this (referring to R4's bruise). Nobody reported that he (R4) has a bruise. On 12/11/23, at 12:16pm, V4 (LPN) inquired how R4 sustained the bruise (R4 responded in Spanish). V4 affirmed A few days before, he (R4) remember a fall, that's what he tell me. On 12/14/23 at 12:40pm, surveyor inquired about R4's bruise. V1 (Administrator) stated, he (R4) told me that he fell and hit the wall with his arm when the CNA was taking care of the roommate. A a male Nurse had also gone into the room. We traced back to see who was working. The CNA (V20) stated, he (R4) was walking around the room bumped into the wall and slid down to the ground, she said he didn't fall. I asked the Nurse (V3) about the incident. He (V3) said, the CNA called me, I (V3) asked did he (R4) fall. She (V20) said, No. I (V1) said if he (R4) was on the floor and fell you (staff) have to do risk management. I had to educate them (V3, V20), if they (residents) crawl to the floor, you lower them to the floor, or they slide to the floor, you have to report it timely. Whoever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 13 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 witness the fall needs to report it to the nurse supervisor regardless of whether they witness it. The nurse needs to assess the resident, communicate with the doctor, and take orders if they (residents) need pain management or further evaluation. They (staff) have to document the incident report on the risk management on the computer. Residents Affected - Few V20's (12/11/23) statement affirms R4 fell on [DATE] (5 days prior to IOUO investigation). The fall management policy (revised 5/2015) states any time a resident sustains a fall, a report of that occurrence is to be completed by the licensed nurse. The family and doctor will be notified of the occurrence. Documentation will support the monitoring, findings and actions taken. A separate accident/incident/unusual occurrence report is to be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 14 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based upon observation, interview and record review the facility failed to ensure that adequate nursing staff were scheduled on the (4th floor) dementia unit, failed to ensure that sufficient nursing staff were available to meet the needs for two of three dependent residents (R3, R4) reviewed for ADL (Activities of Daily Living) care, failed to ensure that staff were aware of required frequency to check and/or change dependent residents, failed to provide (R4) clothing, failed to ensure (R4's) call light was within reach, failed to provide (R4) a clean urinal, failed to timely identify/report/investigate (R4's) injury of unknown origin, failed to ensure staff use proper transfer techniques to prevent falls/injury, failed to revise (R3's) care plan with appropriate transfer interventions (post rib fractures), failed to offload (R1's) wound as directed, failed to follow (R1's) treatment orders, and failed to provide (R1) timely incontinence care to prevent MASD (Moisture Associated Skin Damage). These failures have the potential to affect 55 (4th floor) residents. Findings include: On 11/2/23, 11/13/23, 11/27/23 and 12/4/23 IDPH (Illinois Department of Public Health) received allegations regarding facility lack of staff on the weekends. The (12/11/23) facility census includes 55 (4th floor) residents. On 12/11/23 at 11:35am, surveyor inquired about the current (4th floor) staffing. V4 (LPN/Licensed Practical Nurse) stated, We have these CNAs/Certified Nursing Assistants (referring to the 12/11/23 assignment sheet) we are 7 and affirmed there are 2 Nurses assigned. Surveyor inquired if this was adequate staffing considering acuity of the dementia residents. V4 responded, Usually we have 7 or 8 CNAs, it depends. Sometimes CNAs call off, it could be 6. Surveyor inquired about the current (4th floor) census. V4 replied, We have 55. Surveyor inquired about the (4th floor) CNA staffing last Sunday (12/10/23). V4 reviewed the schedule and replied, Yesterday there were 6 CNAs (referring to the 7am-3pm assignment sheet) and 5 CNAs for evenings (referring to the 3pm-11pm assignment sheet). [The 11pm-7am staffing for 12/10/23 was not in the binder at this time]. Surveyor inquired about the (4th floor) CNA staffing last Saturday (12/9/23). V4 responded, This is 6 (referring to the 7am-3pm assignment sheet) and this was 6 but someone call off so it was 5 (referring to the 3pm-11pm assignment sheet). On 12/11/23 at 11:41am, V5 (LPN) affirmed 4th floor is the Dementia/Alzheimer's unit. Surveyor inquired about the (4th floor) 7am-3pm CNA staffing. V5 stated, Normally we have 7 CNAs but sometimes we have call offs, so we may have 5 or 6. Surveyor inquired if the facility uses Agency staff. V5 responded, We have less now but yes we have that. R4 resides on 4th floor. On 12/11/23 at 11:55am, R4 was lying in bed (alone) however the call light was on the floor and out of reach. Surveyor subsequently inquired about the location of R4's call light. V6 (CNA) entered R4's room and stated, It's by the bed on the floor. Surveyor inquired if R4 could reach the call light. V6 replied, Not from this angle he (R4) couldn't. R4's curtain was pulled; he was somewhat covered with a sheet and completely naked. Surveyor inquired if R4 was dressed. V6 removed R4's sheet and responded, He doesn't have on any clothes, he doesn't have nothing on. Surveyor inquired why R4 was not dressed. V6 replied, He says it be hot, so he doesn't wear them, he takes the clothes off however there were no clothes present. Surveyor observed a large bruise on R4's right arm and requested the assigned Nurse. V6 left the room (without assisting R4) and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 15 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 return. R4 sat up, put a pull-up on and walked to the doorway (undressed). Level of Harm - Minimal harm or potential for actual harm On 12/11/23 at 12:02pm, V4 (LPN) entered the room and assisted R4 to the bathroom. Surveyor inquired about the bruise on R4's arm. V4 stated, With the shoulder? He (R4) has a bruise over there, let me see and assessed the resident. Surveyor inquired how R4 sustained the bruise. V4 responded, I just came back from vacation and affirmed she was unsure. V7 (CNA) entered the room and affirmed she is assigned to R4. Surveyor inquired about R4's clothes. V7 searched R4's closet however only socks were present. V4 (LPN) stated, Usually when we don't have belongings, we get it from community. V7 stated, There's no clothes here for him, this is his locker that he is assigned to basically we just see socks there for him. This morning I dressed him in a gown. Surveyor inquired where R4's gown was located. V7 searched R4's bed and room however unable to locate a gown. V7 (CNA) inquired where the gown was located. R4 replied, Yo no tengo vata V7 responded, He (R4) said he doesn't have it no more, doesn't know where he put it. Surveyor inquired about the appearance of R4's urinal which contained a dried crusty tan substance and a lot of black spots. V4 (LPN) stated, It's disgusting, I'm gonna throw it away this is unbelievable. It's a yellow and black, something old. Surveyor inquired what the black substance in R4's urinal appeared to be. V4 responded, mold. Residents Affected - Some On 12/11/23 at 12:02pm, V4 (LPN) accessed R4's EMR (Electronic Medical Records) and stated, There is no incident there, I don't see any incident put in risk management if we saw something like this (referring to R4's bruise). Nobody reported that he (R4) has a bruise. On 12/11/23 at 12:16pm, V4 (LPN) inquired how R4 sustained the bruise. (R4 responded in Spanish) V4 stated, A few days before, he (R4) remember a fall that's what he tell me. R3 resides on 4th floor. R3's (12/2/23) progress notes state resident has (acute) left lateral fracture on ribs 7, 8, and 9. R3's (12/7/23) care plan states resident has fracture of multiple ribs of left side however mechanical lift transfer (to prevent further harm/injury) is excluded. On 12/11/23 at 12:05pm, R3 was observed (in the dining room) seated in a wheelchair, leaning towards the left side and appeared uncomfortable. At 12:10pm, surveyor inquired when R3 was placed in the wheelchair. V8 (CNA) stated, We got him up like at 7:30(am), it took four of us (staff) to transfer him to the chair. Surveyor requested to inspect R3's incontinence brief. V7 (CNA) and V8 placed a gait belt on R3 (around the fractured ribs) and instructed him to stand however he was unable to do so. R3 was lifted from the chair and stated Don't let me slip as his feet were sliding sideways on the floor. V7 and V8 proceeded to transfer R3 (instead of placing him back in the chair) and almost dropped him on the floor however his butt landed on the mattress which was near the floor (R3 has a low bed). Surveyor inquired if R3 can walk. V8 stated, When I first started around 6 or 7 months ago but not now. You see we have difficulty at him holding up. Surveyor inquired if R3 is able to stand. V8 responded, No therefore mechanical lift transfer is likely required. Surveyor inquired if R3 is able to turn and/or reposition himself. V8 replied, No, he's totally care. The left side of R3's pants appeared wet surveyor inquired when residents are supposed to be checked and/or changed. V8 stated, We're supposed to change em twice at least, at least sometimes three, it depends on their situation with their diaper [every 2 hours and/or as needed was excluded]. Surveyor inquired about the appearance of R3's pants. V8 responded, It's wet. V8 removed R3's brief which was moderately saturated with urine and contained a large bowel movement V8 stated He's wet and dirty. R1 resides on 4th floor. R1's physician orders include (11/20/23) utilize foam wedges or pillow to offload pressure areas. Apply zinc oxide cream to buttocks, sacrum and perineal area every shift after incontinence care. (11/29/23) Sacrum: clean with wound cleanser, apply medihoney, pack open areas (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 16 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 with calcium alginate, cover with foam dressing. Change daily and as needed. Level of Harm - Minimal harm or potential for actual harm On 12/12/23 at 2:07pm, R1 was lying in bed and (on his back) therefore his (stage 4) sacral wound was not off loaded (as directed). Surveyor inquired about R1's wounds V5 (LPN) responded I know the wound care nurse (V15) just changed his dressings and his pouch (re: colostomy) about 10, 15 minutes ago. V16 (Family) at bedside also affirmed that R1's dressing was just changed. V5 removed R1's incontinence brief (as requested) and his right hip was covered with a red rash [likely MASD]. V5 stated, He's got a rash and it's probably from the diaper, it's too tight or if it's not changed often. [zinc oxide cream was not present on R1's skin]. A (4 x 4) border dressing (dated 12/12) observed on R1's sacrum appeared clean, dry and intact. V5 removed R1's border dressing (as requested) the small open area (between the buttocks) had no treatments and/or dressing atop of the wound. The large open area on R1's right buttock appeared to be packed with a dressing however the dressing (outside the wound) had dried sangeunous drainage and was adhered to R1's skin. Surveyor inquired if the dressing packed in R1's wound appeared as if it was just changed. V5 stated, No, the dressing says 12/12 but it doesn't seem like it. It shouldn't be dry; it should be fresh. If it's open or tunneling (referring to the wounds) it should be honey or something like that and it looks dry. Surveyor inquired if a dry dressing promotes wound healing V5 stated No, it has no purpose. Residents Affected - Some The Saturday (12/9/23) daily schedule affirms 2 CNAs and 1 Nurse were scheduled (11pm-7am) on the 4th floor therefore only 3 staff were assigned to care for 55 dementia residents. The Sunday (12/10/23) daily schedule affirms 3 CNAs and 1 Nurse were scheduled (11pm-7am) on the 4th floor however one CNA called off. On 12/18/23 at 3:40pm, surveyor inquired about the facility (4th floor) staffing. V24 (Staffing Coordinator) stated, for 7am-3pm we have 2 nurses and 5-7 CNA's depending on how many staff are available (staffing based upon the census and/or acuity of residents was excluded). 3pm-11pm, we have 2 nurses and 5-6 CNAs. 11pm-7am we have 1 nurse and 3 CNA's. Surveyor inquired what the xxxx indicates on the schedule. V24 responded, That means that there's no one there, no one is in that spot. I can say that we (facility) don't have a lot of call offs. If they (staff) call in like 4 hours before their shift, we'll replace them with somebody. We use agency. Surveyor inquired about the (4th floor) Sunday (12/10/23) 11pm-7am schedule V24 affirmed a CNA called off however no additional staff were added to the schedule. The (12/2018) staffing policy states our facility provides adequate staffing to meet needed care and services for our resident population. Staffing adjustments are made to meet the needs of residents with a diagnosis of dementia or cognitive impairment or other special needs. The direct care staffing policy (revised 1/2/14) states the number of staff who provide direct care who are needed at any time in the facility shall be based on the needs of the residents. The facility shall provide minimum care staff by determining the amount of direct staffing to meet the needs of the residents and meeting the minimum direct care staff ratios set forth in the Administrative Code 77. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 17 of 18 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility to provide a safe environment for residents, staff and the public by blocking an egress door on the 4th floor stairwell. This failure affects 55 residents living on the 4th floor. Findings include: On 12/11/23 at 10:45AM The 4th floor stairwell exit door (next to RM [ROOM NUMBER]) was observed closed and blocked with a soiled linen cart. Surveyor was unable to open the door from the stairwell side. The door was forced open. On 12/11/23 at 10:50AM V1 (Administrator) stated, the staff are not supposed to block the stairwell doors. They probably do that to prevent the confused residents from trying to exit the door. I will address that issue. Facility policy titled Exits or Means of Egress states including: 3. All personal shall keep exits clear at all times. Exit doors should never me blocked , even briefly. 4. Whoever discovers a blocked exit shall clear the exit, if possible, and report the finding to his or her Immediate Supervisor or to a supervisor or manager in the building, if the Immediate Supervisor is not present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 18 of 18