Health inspection·October 1, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note Text: R2 was walking back to her room when writer was informed by staff that resident was smacked by another resident[R1] that was sitting in the hallway. Writer rushed over to separate residents. Resident stated being smacked on her cheek by resident. No complaint of pain at this time. Residents were separated, assessed from head to toe, no visible injuries noted. No complaint of pain. Administrator informed, NP informed, social service informed and family called with no answer, messaged left to please call facility back. R3's clinical record indicates in part: R3 was admitted with muscle weakness, diabetic, anemia, essential hypertension, long term use of insulin, cerebral infarction, and knee joint replacement. Minimum data set brief interview dated 8/23/24 scored [10] indicates R3 is cognitively intact. Interviews: On 9/28/24 at 10:13 AM, R1 stated, I am doing well. I don't remember hitting anyone. I like living here at this facility. I have not been abused and I feel safe here. I take my medication every day. On 9/28/24 at 10:30 AM R2 stated, R1 and I had incident a few weeks ago. I was walking from the dining room, and R1 told me to stop talking about her. I know R1 has a bad memory and is very confused, so I was trying to tell her that I was not talking about her when all the sudden R1 slapped my face. R1 is old and weak, so it did not hurt my face, or leave any marks or bruise. The incident did not make me feel bad or embarrassed. I know R1 was very confused. I never seen R1 act like that before. I did not hit her back, housekeeper and nurse ran over to R1 to calm her down. The nurse came in my room and checked me out. I was fine. The administrator [V1] offered me to move to another floor but I told her that I liked my room and floor I been living on, and I was not afraid of R1. Since R1 came back she has been so nice and pleasant, now I know if she starts saying things that is not true, I will not talk to her, I will tell the nurse. R1 cannot help it, she is so confused. I have not been abused at this facility, I feel safe here, the staff is very nice. On 9/28/24 at 10:40 AM R3 stated, I been living here for a while, and I know R1 and R2. I was in the hallway the day of the incident. R1 thought R2 was talking about her, but that was not true. When R2 tried to explain herself R1 out of nowhere slapped R2 on the cheek. Instantly the housekeeper and nurse came running. R2 did not hit R1 back, everyone knows R1 is very confused and does not know what she is doing. R1 has not hit anyone before, I was surprised that R1 hit R2. R1 went to the hospital and came back a new person. R1 is much nicer, but we know to watch out for her if she get upset. On 9/28/24 at 9:45 AM, V6 [Housekeeper] stated, I saw in the hallway R1 was accusing R2 of something and then all of the sudden, R1 slapped R2 face, and I ran over and called for the nurse to help me. R2 did not strike R1 back she walked away into her room. R1 always sits in the hallway, and I have never saw her act aggressive or hitting anyone. On 10/1/24 at 10:22 AM V9 [Registered Nurse] stated, I was R1 and R2's nurse the day of the incident. V6 [Housekeeper] came and got me and told me that R1 was physically abusive toward R2. I immediately went over to them, R2 walked away and went into her room and R1 was in the hallway talking loudly and agitated. I had staff sit with R1 while I assessed R2. She [R2] did not have any injuries, redness, or pain. R2 said R1 thought she [R2] was talking bad about her and started to argue with her [R2]. R2 said she tried to tell R1 that she was not talking about her, but suddenly R1 slapped her face. R2 said she did not hit R1 back because R1 was confused and agitated. I notified the administrator, physicians, and family member of both residents. R1 was sent out for psych evaluation, we all were so surprised because she never struck another resident here in the facility. R1 returned from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital stable and calm, after adjusting her medication. Prior to this incident R1 did not need close monitoring, she stayed to herself and always appeared calm. R1 does not wonder the unit or had any other signs of aggressiveness. However, now the staff monitor R1's behavior, watching for signs of agitation to prevent any other incidents. Both residents and family agreed to allow both residents to live in their same room. I received abuse training earlier this month. The abuse coordinator is the administrator, some types of abuse are physical, verbal, sexual, and mental. On 9/2/24 at 11:00 AM V4 [Licensed Practical Nurse] stated, I am familiar with R1 and R2. R1 is very confused. I was not here when the incident occurred between R1 and R2. Prior to the incident R1 did not require close supervision, she was calm and like to sit in the hallway or in her room. Since the incident, the nursing staff monitor R1 closely for any signs of aggression or agitation, so we can calm R1 down and keep her from becoming aggressive. Since her medication adjustment, R1 has been calm. On 9/28/24 at 1:22 PM, V10 [Certified Nurse Assistant] stated, I am familiar with R1 and R2. R1 did not need close monitoring, she did not have behaviors like being aggressive towards staff or other residents. I knew about the incident. We were in-serviced to monitor R1 closely and watch for any signs of agitation, or increase in confusion, and report it immediately to the nurse and or social worker for intervention and give R1 the extra support needed to prevent any other incidents. I received abuse training a few weeks ago. The abuse coordinator is the administrator. On 9/28/24 at 11:13 AM V3 [Registered Nurse/Nurse Supervisor] stated, I was not working on the day of the incident between R1 and R2. However, I heard that R1 struck R2. R1 was sent to hospital for a psychological evaluation and medication adjustment. R1 is confused. R1 does not have history hitting other residents. I have not received any other complaints about R1. R2 is alert and oriented X2-3. That was the first time R1 was aggressive towards anyone here at the facility. It has been about a month, and they get along fine, no more aggressive behaviors from R1. On 9/28/24 at 2:44 PM, V2 [Director of Nursing] stated, I assisted V1 with the investigation between R1 and R2. I spoke with other residents on the unit. They all said R1 has not hit them or been aggressive towards them in any way. R1 did not have a documented history of physical aggression. R1 did not require close monitoring, she had not been aggressive since she been here at the facility. I in-serviced the nursing staff on R1's updated care plan and to monitor her closely for sign of agitation, restlessness, and signs of urinary tract infections that my trigger R1 to become more confused and agitated. All nursing staff was in-service this month. During our staff meetings the administrator goes over abuse. R1 was sent to the hospital and treated for urinary tract infection and medications were adjusted. R1 has been calm upon her return. On 9/28/24 at 3:15 PM, V1 [Administrator] stated, R1 is a very confused resident. R1 did not have a history of physical aggression. Staff was interviewed and V6 was in the hallway when she noted R2 walking pass R1, when R1 in a loud voice said to R2 where are you going? R2 said in my room when R1 slapped R2. V6 immediately separated the two residents and called for V5[Registered Nurse] to come and help. Each resident was assessed for injuries, no injuries were noted. The physicians, and families were made aware. R1 has dementia and the behavior was triggered for no reason. At the end of my investigation, R1 was having a mental status change that provoked her to get aggressive with R2. Non-intentional abuse. R1's family and R2's family both wanted both residents to remain on the same floor. R2 and her family was okay with R1 remaining on the same floor, they both refused to move to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm another floor. The staff was in-serviced on watching for signs of agitation, increase in confusion, refusing care, not eating well, or refusing medication to notify the nursing staff, social worker, the physician, and myself for further interventions, such as medial testing of urine, blood work, or adjusting medication and close monitoring to prevent other incidents. During all staff meetings, the staff have an abuse in-service, annually, and all new hires. Residents Affected - Few Reviewed the IDPH reportable initial and final report of 08/25/24. The facility reported incident on 8/25/24 was R1's first incident of aggression. Per interviews R1 prior to the incident did not require close monitoring/supervision. R2 did not sustain any injury and R2 denied any pain at the time of the incident. Policy documents in part: Abuse Prevention Program dated 10/2022. The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, and services by staff or mistreatment. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 4 of 4