Health inspection·August 22, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete yesterday she could not do that anymore due to worsening hand contractures and more limited finger dexterity. V24 stated R118 does not enough external rotation of her shoulder to be able to reach behind her so the call light system needs to be directly in front of her for her to be able to access it. V24 stated the call light string attached to the thick stuffed toy she saw set up for R118 yesterday was not working for her because she could not grasp it and it was too heavy for her to move. V24 stated she removed the stuffed toy and set up a different system which R118 was able to use independently to activate her call light.On 08/21/2025 at 9:50 AM, V2 (Director of Nursing) stated all residents should have access to a call light and the call light should be near the bed and accessible to the resident. V2 stated it is important for the resident to have access to a call light so they can call for assistance. V2 stated if a resident cannot reach the call light or use the call light then it will be hard for the resident to communicate with the staff and call for assistance. V2 stated the facility should be providing a call light system that is functional for the resident and individualized to the resident's abilities. R118 has diagnosis which includes but not limited to Type 2 Diabetes Mellitus, Severe Morbid Obesity, Contracture Right Hand, Contracture Left Hand, Contracture Right Elbow, Contracture Right Ankle, Contracture Left Ankle, Muscle Wasting and Atrophy, Fatigue, Tremor, History of Falling, Unspecified Osteoarthritis, Venous Insufficiency (Chronic), Lymphedema, Chronic Kidney Disease, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. R118's MDS (Minimum Data Set) dated 06/11/25 documents in part, functional limitation impairments to both sides of upper and lower extremities, dependent for activities of daily living and mobility. R118's activities of daily living self-care documents intervention in part, encourage the resident to use bell to call for assistance. R118's fall risk care plan documents intervention in part, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Facility provided document titled Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities dated 11/2018 which documents in part your facility must treat you with dignity and respect and your facility must be safe, clean, comfortable, and home-like. Facility provided policy titled, Answering the Call Light dated 11/2013 which documents in part when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Event ID: Facility ID: 145792 If continuation sheet Page 2 of 20 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 08/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to a.) ensure the Code status matched on the Physician Orders, POLST (Practitioner Order for Life-Sustaining Treatment) and Care Plan and b.) update the care plan to reflect the correct code status for 1 (R8) resident reviewed in a sample of 35.Finding Include:R8 has diagnosis not limited to History of Falling, Transient Ischemic Attack (Tia), and Cerebral Infarction, Anemia, Dementia, Essential (Primary) Hypertension, Schizophrenia, Generalized Anxiety Disorder Osteoarthritis, Nicotine Dependence, Pain in Unspecified Knee, Mild Cognitive Impairment, Chronic Kidney Disease, Multiple Fractures of Ribs, Left Side, Displaced Fracture of Proximal Phalanx of Right Little Finger, Severe Protein-Calorie Malnutrition, Dysphagia, Adult Failure to Thrive, Hyperlipidemia and Gastrostomy. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. Practitioner Order for Life-Sustaining Treatment form dated [DATE] document in part: No CPR (Cardiopulmonary Resuscitation): Do No Attempt Resuscitation. Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management. Allow natural death. Use medication by any route as needed. Use oxygen, suction and manual treatment of airway obstruction. Do not use treatment listed in Full and Selective treatment unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting.Progress note dated [DATE] 15:04 document in part: The care plan was reviewed and updated accordingly. POA/POLST (Power of Attorney/Practitioner Order for Life-Sustaining Treatment) in file. R8's Advance Directives document in part: DNR (Do No Resuscitate) DNR, Full Code (discontinued as of [DATE] 16:42). R8's Care Plan document in part: Focus: Advance Directives POA (Power of Attorney), and R8 will receive education on advance directives. At this time R8 will remain a full code and all life saving measures must be utilized. Date Initiated: [DATE]. Goal: R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE]. Focus: R8 is a Full Code requiring all life saving measures be utilized Date Initiated: [DATE]. Goal: R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE]. Interventions: Assess and notify medical staff of changes. CPR (Cardiopulmonary Resuscitation), O2 (Oxygen), IV (Intravenous), AED (Automated External Defibrillator) as needed. Notify EMS (Emergency Medical Services), 911, and hospitalization as needed, Date Initiated: [DATE].Updated care Plan presented to surveyor on [DATE] document in part: Focus Advance Directives: POA (Power of Attorney), and R8 will receive education on advance directives. At this time R8 Code status DNR. Date initiated [DATE]. R8's wishes will be respected, and staff will take the appropriate measures in the event of an emergency Date Initiated: [DATE].On [DATE] at 10:02 AM V3 (Director of Nursing) stated Social Service is responsible for uploading the Advance Directives POLST (Practitioner Order for Life-Sustaining Treatment) form and updating the Advance Directives care plan. If there is a POLST form the nurse enters the order. The Advance Directives physician order, POLST form and care plan should match. If the care plan does not match the Advance Directives order and POLST form, there will be a conflict of care. Nurse assumes the resident is a full code if there is no proper paperwork as a DNR (Do Not Resuscitate). When we do have the DNR form the resident may still want to go to hospital.[DATE] at 11:21 AM V11 (Director of Social Service) stated social services are responsible for Advance Directives. We explain to the family what the form is and have them fill it out. Administration and the Director of Nursing update the file in the system where it says advance directives and they code it in the system. We upload the POLST form, update the care plan and make sure the POLST forms are signed. Rather Do No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 3 of 20 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 08/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resuscitate or Full Code we upload the file. The care plan is updated the same day the POLST form is signed. R8's care plan should be dated [DATE] when the POLST form was signed. The physician order, care plan and POLST form should match. If they do not match R8 would be incorrectly resuscitated if he is a DNR.Policy:Titled Advance Directives) revised 11/20 document in part: Advance Directives will be we respected in accordance with state law and facility policy. 10. A plan of care for each resident will be consistent with his or her document treatment preferences and/or advance directive. 17. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. 19. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan. 20. The Director of nursing services or designee will notify the attending physician of advanced directives so that appropriate information can be documented in the plan of care.Titled Medical Emergency (Code Blue) revised 06/22 document in part: Purpose: To provide care and services to residents in accordance with Advance Directives that have been discussed with the resident or resident' legal representative in advance of medical emergencies.Titled Care Plans, Comprehensive Person-Centered revised 04/17 document in part: comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team, in conjunction with the resident and resident representative or family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: j. Reflect the resident's expressed wishes regarding care and treatment goals. 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. Event ID: Facility ID: 145792 If continuation sheet Page 4 of 20 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 08/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan that includes measurable objectives with timeframe and interventions to address a resident's language barrier and communication needs for one (R5) out of one resident reviewed for communication in a final sample of 35. Findings Include:On 8/19/25 at 12:12 PM, R5 was sitting up in her wheelchair alert and verbally responsive. Surveyor attempted to interview R5 but started talking in a foreign language. R5 stated, Spanish. Surveyor asked V33 (Certified Nursing Assistant) to interpret. R5 stated that if no one speaks Spanish, they can't explain to R5 the medications that they are giving. R5 stated that not all the time there is someone in the facility to interpret in Spanish. On 8/21/25 at 11:09 AM, V11 (Director of Social Services) stated that language barrier and communication needs are assessed upon admission and reevaluated quarterly. V11 stated that language barrier needs should be addressed in the care plan so that the staff who takes care of the resident is aware of the needs and what to do for the resident. V11 stated that the communication books are accessible in the nurses' station on each floor so they can use it whoever needs them. V11 stated R5 only speaks and understands English, and it should be addressed in her care plan. V11 stated she must have missed including it in R5's care plan.R5's clinical records show a re-admission date of 3/15/25. R5's Quarterly Minimum Data Set (MDS) dated [DATE] shows R5's preferred language is Spanish. It also shows R5 has moderate impairment with cognition. R5's comprehensive care plan does not address R5's language barrier.The facility's Communication Program policy dated 6/7/22 documents in part: Resident is assessed during the completion of the MDS and appropriate CAA (Care Area Assessment) reviews. Deficits in the areas of hearing, vision, speech, foreign language and/or dementia will be documented and discussed at the care plan conference. The IDT (Interdisciplinary Team) will develop sensible approaches designed to facilitate expressive and/or receptive communication. The approaches will be documented in the plan of care. The Care Plan will indicate what deficits exist and are being addresses. The facility's Care Plans, Comprehensive Person-Centered policy dated 4/17 documents in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Event ID: Facility ID: 145792 If continuation sheet Page 5 of 20 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 08/22/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an environment as free from potential accidents hazards as is possible by failing to (a) ensure that a resident (R153) did not have a retractable blade in their possession, (b) implement interventions to properly supervise a resident (R14) with a history of multiple falls, and (c) follow interventions for fall prevention for a resident (R15) who had multiple falls. These failures have the potential to affect three residents reviewed for accidents hazards. Findings include: R153's 'admission Record' documents in part diagnoses of major depressive disorder, single episode, moderate; tremor; generalized anxiety disorder; schizophrenia; unspecified psychosis not due to a substance or known physiological condition; and hallucinations. R153's 7/28/2025 MDS (Minimum Data Set) assessment documents in part that R153 is cognitively intact. It also documents in part that R153 had moderately severe depression. During the look-back period, R153 had delusions and hallucinations. R153's 'Care Plan Report' documents in part that R153 may have some controlling behaviors due to R153's diagnosis of schizophrenia (12/16/2024). On 8/19/2025 at 11:00 AM, R153 was alert and oriented to person, place, and year. R153 had an orange and pear on the bedside table. R153 was using a red, retractable blade to cut the fruits. While holding the blade upright, R153's hands were shaking. R153 stated [R153] got the retractable blade from a friend a while ago. R153 stated [R153] hasn't told anyone [R153] has it. R153 stated using it to cut [R153's] food. R153 stated locking up the retractable blade in the top drawer of [R153's] dresser. R153 washed the retractable blade in the sink, placed it in the top drawer, and locked it. R153 kept the key to self. At 11:14 AM, V12 (Nurse) stated didn't know R153 had a retractable blade. V12 stated R153 is not supposed to have a blade. V12 stated it is not safe for anyone to have it. V12 went to R153's room to retrieve the retractable blade but R153 did not want to hand it over. R153 stated [R153] keeps the retractable blade locked in the drawer. V12 stated will get social services involved. At 11:21 AM, V13 (Social Worker) stated not knowing that R153 had a retractable blade. V13 went into R153's room and asked for the retractable blade. R153 did not want to hand it over. R153 stated [R153] had it locked in the upper drawer each time. V13 called the nurse over. At 11:24 AM, V12 and V13 entered R153's room to retrieve the retractable blade. R153 unlocked the top drawer and handed the blade over to V12. Surveyor used a wound measuring tape from V12 to measure the blade. When fully engaged, the blade measured to 7.5 cm (centimeters). At 12:26 PM, V14 (Nurse Practitioner) stated R153 is alert and oriented but can get confused with active infection but does not have a current infection. V14 stated in the past, R153 would hallucinate but has not done that in years. V14 stated R153 does have Parkinson's. V14 stated [V14] does not see a need for R153 to have the retractable blade. V14 stated R153 probably wouldn't do anything (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 6 of 20 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 08/22/2025 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 harmful with the blade. Level of Harm - Minimal harm or potential for actual harm At 12:47 PM, V2 (Assistant Administrator) stated did not know R153 had the blade. V2 stated R153 and R198 (R153's roommate) are alert and oriented with no behaviors. Residents Affected - Few At 12:55 PM, V3 (Director of Nursing) did not know R153 had a blade. V3 stated R153 is alert and oriented to person, place, and date. V3 stated R153 does not have behaviors and is not a danger to self or others. V3 stated [V3] would not be afraid of R153 doing harm to anybody. V3 stated regardless, a blade is a blade, and residents aren't allowed to have blades because it wouldn't be safe. V3 stated a blade can be misplaced and anybody can take it. V3 stated the facility must make sure it doesn't get into the wrong hands. V3 stated no wanderers on the first floor with most being alert and oriented. At 1:06 PM, V4 (Assistant Director of Nursing) did not know R153 had a blade. V4 stated R153 is alert and oriented to person, place, and date. V4 stated R153 hasn't had any behaviors in years. V4 stated R153 has been pleasant and there are no concerns for self-harm or harm to others. V4 stated residents aren't allowed to have blades because they can injure themselves even if not intentionally and can injure somebody else. On 8/20/2025 at 3:03 PM, V1 (Administrator) stated staff turned over R153's retractable blade to V1 yesterday. V1 stated staff also searched the remainder of R153's possessions and no other contrabands found. V1 stated when V1 questioned R153, R153 stated getting the blade from the garbage can. V1 stated educating R153 to not have blades or knives. V1 stated instructing R153 to inform facility if R153 needs assistance cutting fruit. V1 stated the blade looked like a box cutter. V1 stated not knowing if R153 obtained it somehow due to facility's current remodeling construction on the first floor. V1 stated educating staff and contractors to not leave sharp objects such as blades unattended. V1 also educated them that if sharp objects need disposal, staff and contractors need to do it properly and not within residents' access. V1 stated if facility suspects a resident from bringing in contrabands, they will usually search their items, but facility has not suspected R153 of it. During the follow-up interview with R153 at 3:14 PM, R153 stated finding the retractable blade in a garbage can in the hallway almost 10 years ago. R153 stated having the blade for years and always locking it up in the drawer after use. Facility provided a copy of their admission Packet which includes the Illinois Long-Term Care Ombudsman Program 'Resident Rights' for People in Long-Term Care Facilities document. In documents in part residents' rights to safety. Your facility must be safe, clean, comfortable, and homelike. Facility's 'Accidents and Incidents: Supervision, Investigating and Reporting' policy (rev 06/2022) documents in part: The facility provides an environment that is free from accident hazards over which the facility has control. The facility provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying hazard and risk, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, monitoring for effectiveness and modifying interventions when necessary. Facility's 'Search and Confiscation Policy' (4/24/2022) documents in part that prohibited items include sharps, razors, knives, weapons, or items considered a possible danger. ---------------------------(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 7 of 20 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 08/22/2025 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 Findings include: Level of Harm - Minimal harm or potential for actual harm On 8/19/25 at 11:36 AM, R14 was sitting up in his wheelchair in his room. Surveyor asked if R14 remembers falling in the last six months. R14 stated [R14] does not remember falling. R14 was noted with forgetfulness and bouts of confusion, was unable to verbalize R14's current location, time, and day. Residents Affected - Few On 8/19/25 at 11:39 AM, R173 was lying in bed alert and verbally responsive. R173 stated [R173] remembers R14 falling a couple of months ago. R173 stated R14 was yelling for help. R173 stated it happened in the afternoon but does not remember the exact date and time. R173 stated [R173] pulled the call light to get help and the nurse (does not remember nurse's name) came in right away. On 8/19/25 at 3:45 PM, V10 (Registered Nurse) stated, I was called by [R173]. I answered the call light, and I saw [R14] sitting on the floor next to the bathroom by his wheelchair by the bathroom door. [R14] was trying to go to the bathroom. [R14] said he had to use the bathroom. I asked why [R14] didn't call for help and he said he could do it himself. The wheelchair was unlocked. [R14] was wearing his shoes. [R14] was not in bed. [R14] could propel himself on the wheelchair, but he needs extensive assist with one person to go to the washroom. [R14] is continent of bowel and bladder. I cannot remember off the top of my head the last time [R14] was toileted. I can't remember who the CNA [Certified Nursing Assistant] at that time was. [R14's] call light was clipped on his bed. [R14] needs constant cuing and re-direction. [R14] was educated how to use the call light. [R14] is forgetful and gets confused. [R14] is at risk for fall due to poor cognition. [R14] used to be independent so he tends to not call for help at times. [R14] would get up by himself without asking for help. I've seen [R14] last in the day room about an hour and half before the fall. When he's [R14] up on the chair someone has to always watch him [R14] and monitor him constantly. I can't recall how [R14] got to his room by himself. I did a full body assessment, and he was noted with no visible injuries. He didn't complaint of pain. On 8/20/25 at 12:17 PM, V21 (Restorative/Rehab Licensed Practical Nurse Manager) stated, The falls interventions are developed depending on their progress notes, the root cause of the fall and interview of the patient. For residents who are forgetful and have the tendency to not ask for help, we do a lot of redirections and varies from patient to patient. It's individualized. The staff do a lot of supervision. The staff provides constant monitoring. They must be supervised at all times to go to the toilet for safety and to prevent them from falling. For [R14] he requires extensive one person assistance for toileting. Transfer [R14] requires supervision. [R14] is able to propel himself on the wheelchair, but he still needs supervision because [R14] has the tendency to get up by himself. Since February [R14] had three falls. The 3/11/25 fall [R14] was attempting to get out bed. On 3/12/25, [R14] had another fall trying to go to the toilet by himself. On 3/25/25 [R14] was also found on the floor in his room. [R14] slid out of the wheelchair. Prior to the 3/25/25 fall [R14] was placed on falling star program it's a yellow sticker by the door. It tells the staff that [R14] is high risk for falls that staff should always assist him and not to leave him alone when [R14] is up on his wheelchair because [R14] is a frequent faller. [R14] needs constant monitoring. R14's clinical records show an original admission date of 3/30/16 with listed diagnoses but not limited to unspecified dementia, muscle weakness, generalized anxiety disorder, and history of falling. R14's Minimum Data Set, dated [DATE] shows R14 has moderately impaired cognition and requires supervision or touching assistance with transfers and toileting. Facility's Post Fall Evaluation dated 3/25/25 revealed R14 was observed on the floor in his room attempting to self-toilet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 8 of 20 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 08/22/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few The facility's Fall Star Program Policy dated 11/2013 documents in part: To ensure that all residents determined to be at risk for falls or who have fallen are properly monitored the facility may initiate the falling star protocol. The facility's Falls – Clinical Protocol dated 6/22 documents in part: Based on the preceding assessment, the staff and physician or LIP will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. ---------------------------Findings include: R15 is [AGE] years old, initial admission date of 03/04/2024. R15 medical diagnosis includes Parkinson's disease, syncope and collapse and bipolar disorder. Per R15's clinical notes, resident (R15) has multiple falls on 02/03/2025, 03/01/2025 and 03/23/2025. Review of R15's care plan intervention documents that R15 needs non-skid under mattress dated 03/01/2025 and personal items within reach among other. On 08/21/2025 at 10:00 AM V21 (Restorative Rehab Manager/Licensed Practical Nurse) stated that R15 mostly dependent on her ADLs (Activity of Daily Living). V21 confirmed that R15 fell three (3) times on 02/03/2025, 03/01/2025 and 03/23/2025. And intervention that was placed to prevent R15 from falling is to place non-skid pad underneath the bed, place the bed in low position and personal items within reach. V21 stated that the fall dated 03/01/2025 was due to mattress moved or slid off the bed. Nursing notes dated 03/01/2025 by V5 (Registered Nurse/Infection Control) documents that the bed slightly sliding to the floor when R15 fell. On 08/21/2025 at 10:00 AM with V21 inside R15's room. R15's mattress was seen without non-skid pad underneath. There were straps on the mattress that was not attach to the bed. Mattress on the bed was light weight that can be moved with one hand. V21 said that there needs to have non-skid pad, and strap needs to be attached for bed not to move. V21 then lowered the bed on its lowest position. V21 stated that the bed needs to be lowered as part of fall prevention. Side table with cabinet where all personal items (bottle of lotion, personal toiletries) of R15 was seen out of reach/hard to reach. V21 stated that bed needs to move closer to the side table cabinet to reach the items. And the bed was light in its weight that it can moved and make R15 fell. Nursing notes dated 03/23/2025 by V8 (Registered Nurse) documents that R15 fell when she was reaching for item(s). Falling Star Program Policy dated 11/2013: To ensure that all residents determined to be risk for falls or who have fallen are properly monitored that facility may initiate the falling star protocol. Recommendation and updating of individualized interventions will be implemented and documented on the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 9 of 20 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 08/22/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review the facility failed to place oxygen in use signage on the door of one (R159) resident out of five residents reviewed for respiratory care in a sample of 35. Findings include: On 08/19/2025 at 12:15 PM, observed R159 lying in bed with oxygen infusing via nasal canula. R159 did not have an oxygen in use sign or no smoking sign posted in or outside his room.On 08/19/2025 at 12:30 PM V8 (Registered Nurse) stated if a resident is on oxygen, then they have to have an oxygen in use/no smoking sign posted outside their door to alert people that oxygen is in use. V8 stated the sign is a safety precaution. V8 stated if there is a fire the resident's doors are closed but the oxygen in use sign posted outside the door would still be visible which is important for staff and fire personnel to be able to quickly identify who is at risk. V8 stated R159 is on continuous oxygen. V8 looked on the outside of R159's door and stated there is not an oxygen in use/no smoking sign posted and there should be one. V8 stated R159 recently returned from the hospital, and someone forgot to post the sign when he was readmitted . V8 stated he will go and get a sign right now to post outside R159's room.On 08/21/25 at 9:46 AM, V2 (Director of Nursing) stated if a resident is receiving oxygen there should be a no smoking/oxygen in use sign posted on the outside of the resident's room. V2 stated the purpose of the sign is to alert family and residents that they should not be any smoking inside or near the room. V2 stated it is a hazard and signage is posted for safety. V2 stated R159 was readmitted from the hospital and there should have been a no smoking/oxygen in use sign posted when he was readmitted outside his door. R159's diagnosis included but not limited to Chronic Respiratory Failure, Unspecified Dementia, Severe Intellectual Disabilities, Seizures, Epilepsy, Obstructive Sleep Apnea, Visual Loss, Dysphagia, Adult Neglect or Abandonment. R159's Order Summary Report dated 08/19/25 documents in part oxygen continuous oxygen via nasal cannula/mask at 2 liters per minute every shift. R159's oxygen care plan undated documents in part R159 has altered respiratory status/difficulty breathing related to chronic respiratory failure, obstructive sleep apnea. Facility provided policy titled, Oxygen Administration dated 03/2020 which documents in part, place an Oxygen in Use sign in a designated place on or over the resident's bed. Facility provide policy titled, Oxygen Care and Storage dated 12/2017 which documents in part, No Smoking signs must be clearly visible in areas where oxygen is stored or in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 10 of 20 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 08/22/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to administer medication according to the physician's order for 1 (R107) of 4 (R6, R147, R202) residents reviewed during medication administration.Findings Include:R107 has diagnosis not limited to Epilepsy, Delirium due to Known Physiological Condition, History of Falling, Disorders of Brain, Muscle Weakness (Generalized) and Cognitive Communication Deficit. R107's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 09 indicating moderate impairment.Order Summary Report document in part: Dilantin Oral Capsule 100 MG (Phenytoin Sodium Extended) Give 4 capsule by mouth in the morning for Epilepsy.R107's Care Plan document in part: Focus: R107 has a seizure disorder, Epilepsy. Is at risk for potential complications; fall, injury, abnormal labs Date Initiated: 06/24/25. Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness.On 08/19/2025 9:43 AM RN V8 (Registered Nurse) prepared Resident #107 medication. Surveyor asked V8 how many pills were in the medication cup. V8 responded there are 8 pills in the medication cup. V8 entered R107's room and administered the medications. 1. Aspirin 81 mg chewable2. Depakote 500 mg bid 3. Phenytoin 4 capsules 100 mg daily V8 only administered 1 capsule 4. Sertraline 50 MG5. Januvia 100 MG6. Magnesium Oxide 400 mg 7. Metformin 500 mg8. Gabapentin 300 mg On 08/21 at 08:47 AM V8 (Registered Nurse) was observed standing at the medication cart on the second floor. Surveyor asked V8 if he would administer R107's medication how many pills would be given. V8 looked into the computer then counted the number of pills that showed on the screen. V8 responded, I would give 8 pills. Surveyor asked V8 to read R107's order for the Phenytoin. V8 said, I gave 1 pill and should have given 4 pills. R107 need the Phenytoin for his seizures and if you don't give right amount R107 could have a seizure.On 08/21/25 at 10:02 AM V3 (Director of Nursing) stated Prior to given medications the nurse should take a look at the 5 rights. The right order, right dose, right time, right patient and right route. V107's order for Dilantin (Phenytoin) is give 100 mg, give 4 capsules by mouth in the morning. If the correct dosage of the Dilantin is not given it is a missing medication and there is a potential if not receiving the correct dosage it will affect the Dilantin level and by not receiving the right dosage R107 could have seizures.Policy:Titled Administering Medications revised 11/20 document in part: Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications are administered according to physician's orders unless otherwise specified. 7. The individual administering the medication must check the label THREE (3) times to verify right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 11 of 20 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 08/22/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to a.) ensure expired medications and fiber fortified formula were removed from 1 of 2 medication rooms b.) ensure expired medications were removed from 2 of 4 medication carts and c.) ensure medications were properly labeled and dated in 1 of 4 medication carts reviewed for medication storage and labeling.Finding Include:On 08/19/25 at 09:53 AM the Second Floor Short End Medication Cart was reviewed with V9 (Registered Nurse). R98's Erythromycin 0.5 % eye ointment and Azelastine HCL 0.05% 1 drop both eyes Twice a day was observed in the medication card drawer with an open date of 05/11/25 and expiration date of 06/07/25 written on the boxes. V9 stated they should have been discarded. They were opened on 05/11/25 and expired 06/07/25. R174's lispro insulin multi dose vial was observed in the medication cart drawer with an open date of 07/21/25 and a discard date of 08/18/25. Surveyor asked V9 the dates that were written on the insulin vial label. V9 responded, 07/21/25 and it look like a 6 for 06/18/25. I guess it's an 8. The medications should have been removed from the medication cart drawer. If the resident receives expired medications, there is a potential they could have adverse side effects.On 08/19/25 at 12:38 PM the Fourth Floor Medication Room was reviewed with V10 (Registered Nurse). One open box with an undated vial of Tuberculin Purified Derivative Mantoux 5 tu (tuberculin units) 0.1 ml intradermal was observed in the refrigerator. V10 stated the tuberculin is good for 30 days from the date when it was opened. Ten 8-ounce cartons of Osmolyte 1.5 cal. With an expiration date of 09/24 was observed on a shelf in the medication room. V10 stated we use it in the g (gastric) tube, and we discard them when they expire. If a resident receives the Osmolyte they will probably get an upset stomach.On 08/21/25 at 10:47 AM the 1st floor medication cart was reviewed with V12 (Licensed Practical Nurse) R19's Basaglar insulin pen was observed in the medication cart drawer with no name or dated and R19's Aspart insulin flex pen was observed in the medication cart drawer with no open date. V12 stated they should have been labeled when they were opened, to know when we opened it and to know when we should discard it. R167's Lantus insulin vial was observed in the medication cart drawer with a label documenting opened 07/20/25, expiration date 08/20/21. V12 stated the Lantus insulin vial is expired as of 08/20/25. V12 then removed the Lantus insulin vial from the box and placed it in the sharp's container.On 08/21/25 at10:02 AM V3 (Director of Nursing) stated for the Tuberculin they supposed to be labeling the PPD (Purified Protein Derivative) when they open it with an open date so they can properly discard it. Outside of the discard date it is a medication error, but I am not sure if it causes any adverse reactions. I will take a look. I don't know why the Cartons of Osmolyte were there. There are no residents on that floor that is on Osmolyte. If the Osmolyte is expired, it should not be there. There is a potential adverse reaction-like diarrhea, and I already started education. My expectations for the Insulin Multi Dose Vial are that it has an open and expiration date. If it is past the expiration date, we should remove the vial and we should not be using the vial that is expired. Most insulin is good for 28 days once opened. If used after the discard date, there is a potential that the medication will not be as effective. Eye Drops with an open date of 05/11/25 and a discard date of 06/07/25 should have been removed because the Erythromycin eye ointment was completed and expired. The Azelastine eye drops should have been removed because it was expired. There is a potential that the eye ointment and eye drops would not work the same way and could irritate R98's eyes.Email presented to the surveyor on 08/21/25 11:22 AM document in part: Please see attached requested package insert for Tubersol solution. A vial of Tubersol which has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 12 of 20 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 08/22/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete been entered and in use for 30 days should be discarded.Document titled Tuberculin Purified Protein Derivative (Mantoux) Tubersol undated document in part: A vial of Tubersol, which has been entered and in use for 30 days should be discarded. Do not use after expiration date.PolicyTitled Storage of Medication and Medical Supplies revised 12/17 document in part: The facility shall store all drugs [NAME] biologicals and medical supplies in a safe, secure and orderly manner. 2. Medical supplies are to be stored in order of their expiration date and in original packaging or container. 3. Damaged or expired medical supplies are not to be used. These supplies are to be discarded. 6. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 14. Multiple dose vials such as insulin shall e dated the day they are opened and with the expiration date. 17. Expired medications are to be disposed of.Titled Administering Medications revised 11/20 document in part: 9. The expiration/beyond use date on the medication label must be checked before administering. When opening a multi-dose container, the date opened shall be recorded on the container. Event ID: Facility ID: 145792 If continuation sheet Page 13 of 20 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 08/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of records the facility failed as follows: Failed to maintain refrigerated food labeled, dated and without signs of deterioration. Failed to ensure food stored on dry storage that was opened are labeled and dated, canned food follow first in first out policy. Failed to maintain clean environment with shelves use to accommodate plates, fans used circulating air on unclean condition. Failed to follow policy on handwashing/hand hygiene prior to food preparation on the tray line and after touching high touched areas. These failures are not in accordance with their policy and can affect all 200 residents living in the facility with two (2) residents on NPO or not taking food by mouth on the quality of food received during meals. Finding includes: On 08/19/2025 at 09:29 AM, V6 (Dietary Aide) informed writer that V7 (Dietary Director or Food Service Manager) will not report today. And she (V6) will help with the review on the kitchen. During initial tour shelves near the tray line was found with dirt when scrapped by finger. V6 stated that cleaning usually is done Mondays and Fridays. At dry storage room, a transparent bag of bread ends from multiple loaves of bread was seen on top of the shelf that has loaves of bread stored on other level of the shelf. V6 stated it was not dated and it needs to be discarded. Upon checking the shelves with large can food. Dice tomato cans dated 07/20/2026 was in front of 08/07/2025, [NAME] orange cans 07/10/2026 was in front of 08/11/2026. V6 stated that it was not arrange in accordance with first in first out policy they follow. Inside walk in cooler, transparent bag of cilantro without a date or almost vanishing marker written that cannot be read found visually discolored like deterioration was seen. V6 took the bag saying, these needs to be discarded. Onions inside a large box without label or date. V6 stated that onions usually is not dated. V6 was asked how staff determines when onions are still good? V6 replied, it needs to have a date. Prepared super cereal was marked with date of 08/16/2025 with use by date 08/20/2025. V6 stated super cereal can only last 2 or 3 days. V6 said, I do not know why they put that date. At stove / oven area there is a floor fan that was used. V6 turned off the fan, and saw dirt on the fan blades, and fan guards after swiping with finger. V6 stated, I see what you mean, the fan may circulate around. On 08/20/2025 at 11:25 AM, during tray line review. There are three (3) kitchen staff present during review. Included on food preparation at the tray line was V6 and V20 (Cook), prior to start of food preparation V20 did not perform hand hygiene, put on his gloves and started to prepare food touching with his gloves. V20 was seen went to microwave touched multiple times the handle to heat food. Took the food out of the microwave by his gloves. And resume touching food during preparation. At 11:50 AM, V7 (Dietary Director or Food Service Manager) arrived at the kitchen stated that staff needs to perform hand washing before food preparation on the tray line. V7 was made aware about V20 holding microwave handle during food preparation. At about the same time V7 saw V20 again opening microwave by pulling the handle. V7 called V20 attention to perform handwashing. V7 made aware about concerns that was seen the day before. V7 stated that cilantro needs to be taken out of the refrigerator. V7 breads ends need to be labelled and dated, and it is being used for puree. V7 to a plastic container that have bread ends inside. V7 confirmed that she was notified about the shelf and fan being used that was not cleaned. V7 stated that onions do not need to be labeled. V7 reviewed refrigerated food policy that reads: Food in the refrigerator will be covered, labeled and dated. V7 stated that best practice is to date and label food in the fridge per policy. V7 presented document that reads: Suggested Guide for Dating Fresh Fruit and Vegetables. Under the list onions suggest being dated for seven (7) days. The following policies are provided by facility: Storage of Refrigerated Foods dated 2010: Food supplies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 14 of 20 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 08/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete received will be stored in a manner that will ensure preservations of nutritive value and quality. Food in the refrigerator will be covered, labeled and dated. Labeling and Dating Foods dated 2010: Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. For dry stores, cans will be labeled with the date received when unpacked from cases. Newer cans will be placed behind previously received product on the shelf or in the can rack. For refrigerated stores, food prepared on the premises to be held cold will be labeled with the date of preparation and time as required for cooling purposes. This food will also be labeled with date to discard or use by. The discard / use by date will be a maximum of 6 days after preparation. Storage of Dry Goods / Food dated 2010: Non-refrigerated foods, disposable dishware and other dry goods will be stored in a clean, dry area, which will be free from contaminations. Cans will be removed from cartons, dated and stored behind shelves products (FIFO method). First-In-First-Out dated 2021: To ensure food quality and food safety, food products are rotated. The first food product placed in storage is the first one to removed and used. New products are placed on the shelf behind the food products on hand. Products with the earliest expiration date are stored in front of product with later dates so that the older food is used first. Handwashing dated 2021: Food and nutrition services employees will practice safe food handling to prevent foodborne illness. Food and nutrition services employees will thoroughly wash their hands and exposed areas of their arms with soap and water in the designated hand-washing sink at the following times: Before engaging in food preparation. After handling soiled equipment and utensils. Event ID: Facility ID: 145792 If continuation sheet Page 15 of 20 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 08/22/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to practice infection control and prevention measures to:a. Ensure staff performed hand hygiene and wear appropriate Personal Protective Equipment (PPE) when caring for a resident (R209) on Contact Isolation Precautions.b. Educate family on hand hygiene procedure to follow for a resident (R103) on Enhanced Barrier Precautions (EBP). These failures have the potential to affect R209 and all 55 residents residing on the 3rd floor. c. Appropriately handle and transport linen to prevent potential contamination. These failures have the potential to affect all 202 residents residing in the facility. d. Follow their policy and post clear Enhanced Barrier Precaution (EBP) signage on the door or wall outside of a resident's (R20) room for 1 out of a total sample of 35 residents.e. Maintain food supply (ice cube) used by residents for consumption. These failures have the potential to affect all 54 residents with 1 resident on NPO or does not take food by mouth on maintaining clean food (ice cubes) for consumption.Findings include: Residents Affected - Many On 08/19/2025 at 1:14 PM, observed Contact Isolation sign in English and Spanish posted on the outside of R209's door with adequate supply of PPE outside the door. On 08/19/2025 at 1:18 PM, observed inside R209's room hand sanitizer dispenser mounted to the wall filled with hand sanitizer. On 08/19/2025 at 1:22 PM, observed V17 (Certified Nursing Assistant) enter R209's room without performing hand hygiene and without putting on gown and gloves. V17 exited R209's room with R209's lunch tray in hand. On 08/19/2025 at 1:25 PM, V16 (Licensed Practical Nurse) stated R209 is on contact isolation because she has ESBL in her urine and that anyone going into R209's room should do hand hygiene and wear a gown and gloves and dispose of the gown and gloves inside the room before exiting. On 08/19/2025 at 1:29 PM, V17 stated he went into R209's room to collect her finished lunch tray. V17 stated he was not paying attention and did not see that R209 was on Contact Isolation Precautions. V17 said, I'm just seeing that now. I should have done hand hygiene and worn a gown and gloves. On 8/19/2025 at 12:18 PM, observed Enhanced Barrier Precaution (EBP) sign posted on the outside of R103's door in English and Spanish with stocked personal protective equipment (PPE) storage container outside R103's room. Observed hand sanitizer wall dispenser located on the inside wall of R103's room next to the door containing hand sanitizer. On 08/19/2025 at 12:24 PM, observed V15 (103's Family Member) leave R103's room without performing hand hygiene before leaving or after leaving the room in the hallway. On 08/19/2025 at 12:26 PM, observed V15 walk back into R103's room carrying his lunch tray and sit down and begin feeding R103. V15 did not perform any hand hygiene before entering or upon reentering R103's room. On 08/19/2025 at 12:26 PM, V8 (Registered Nurse) stated R103 is on EBP because he has a indwelling urinary catheter and the EBP guidelines are being followed for R103's protection. V8 stated anyone entering R103's room should use hand sanitizer or wash their hands and do it again after leaving the room. R103 stated staff/visitors only need to wear a gown and gloves if they directly touch the resident when providing care. V8 stated the resident's family is provided with education and given the rational of why the resident is on EBP so they understand what needs to be done and why it is important to do it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 16 of 20 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 08/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 08/19/2025 at 12:40 PM, V15 stated she visits the facility almost every day, alternating with her other siblings. V15 stated she did not receive any education or instruction from the staff on EBP. V15 stated the staff did not tell her anything about handwashing or using hand sanitizer before and after entering the room and she is not aware of any of her family members receiving education on it either because none of them said anything to her about it. V15 stated as a matter of habit she washes her hands with soap and water when she first comes into R103's room but does not do it again for the rest of her visit or when she leaves the room and comes back into it. On 08/20/2025 at 12:00 PM, V5 (Infection Preventionist/Registered Nurse) stated R209 was admitted on [DATE] from the hospital where she was on isolation in for +ESBL urine and had completed her antibiotic course. V5 stated she will keep R209 on Contact Isolation Precautions for 72 hours in case she becomes symptomatic and that is why the signage for Contact Isolation Precautions is posted outside R209's room. V5 stated the staff should be doing hand hygiene and wearing a gown and gloves when entering R209's room and doing hand hygiene again when leaving the room and removing the gown and gloves before exiting the room. V5 stated the problem with staff not wearing PPE and doing hand hygiene is that they could contaminate other residents via cross contamination and that is how MDRO's are born. On 08/20/25 at 12:15 PM, V5 stated residents are put on EBP if they have medical devices such as indwelling urinary catheter. V5 stated those residents are more suspectable to acquiring an infection so the EBP are in place as a preventative measure. V5 stated if the staff or visitors are not following the EBP guidelines that could make the resident sick by introducing an infection to the resident. V5 stated anyone entering the room of a resident on EBP should do hand hygiene and do it when leaving the room including family/visitors. V5 stated education is done with family members to explain to them why the resident is on EBP and the preventative measures which should be followed. V5 stated educating the family is important for the protection of the resident. V5 stated family education is done verbally, not necessarily documented. V5 stated R103 is on EBP because he has an indwelling urinary catheter. V5 stated she spoke with R103's son in the past to let him know about the EBP precautions but does not remember when specifically. V5 stated R103 has a big family; she did not talk directly to R103's daughters about EBP. On 08/21/25 at 9:34 AM, V2 (Director of Nursing) stated residents who have a physician order for contact isolation have signage posted outside their room to let the family/staff know that the resident is on contact isolation and what they need to do before entering/exiting the room. V2 stated anyone entering the room of a resident on contact isolation needs to preform hand hygiene and put on a gown and gloves before entering the room and before exiting the room the gown and gloves should be discarded and thrown out inside the resident's room and hand hygiene needs to be performed again before leaving the room. V2 stated it is important for staff to follow these precautions so as not to spread the infection to others. V2 stated R209 is on contact isolation for ESBL urine and anyone entering her room should have followed the guidelines as posted on the signage On 08/21/25 at 9:43 AM, V2 stated EBP barrier precautions are in place to prevent the spread infection. V2 stated everyone including visitors/family members entering a room of a resident on EBP should perform hand hygiene before and after leaving the room. V2 stated Infection Prevention Nurse provides this information to the family and documents when the education is provided in progress notes under education. V2 stated it is important to provide education to family/visitors, so they know to do hand hygiene before entering and when leaving the room. V2 stated the potential problem if family/visitors are not doing hand hygiene is they could be spreading infection. R209's diagnosis included but not limited to Hemiplegia and Hemiparesis Following Cerebral Vascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 17 of 20 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 08/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Disease, Type 2 Diabetes Mellitus, Acute Kidney Failure, Heart Failure, Ileus, Epilepsy, Iron Deficiency Anemia, Long Term Use Of Antithrombotics/Platelets, Cutaneous Abscess Of Right Lower Limb, Contracture To Left Knee, Contracture To Left Hand. R209's Order Summary Report dated 08/19/25 documents in part single room strict contact isolation for ESBL of the urine every shift for infection control. R209's care plan documents in part R09 has a diagnosis of ESBL in urine. Single room strict contact isolation for ESBL of the urine. Single room prophylactic for contact isolation of ESBL in the urine with goal of ESBL will colonize without complications. R103's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease, Acute And Chronic Respiratory Failure With Hypoxia, Interstitial Pulmonary Disease, Dementia, Centrilobular Emphysema, Moderate Protein-Calorie Malnutrition, Asthma, Cholecystitis, Encounter For Fitting And Adjustment Of Urinary Device Foley Catheter, Bilateral Inguinal Hernia, Hypotension, Neuromuscular Dysfunction Of Bladder, Retention Of Urine, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Calculus of Gallbladder Without Cholecystitis Without Obstruction, Other Specified Disorders Of Kidney And Ureter, Nodular Prostate With Lower Urinary Tract Symptoms, Adult Failure To Thrive, Obstructive And Reflux Uropathy, Unspecified Cyst Of Epididymis. R103's Order Summary Report dated 08/19/25 documents in part Enhanced Barrier Precautions (Foley) every shift for EBP and Foley Catheter size 16 French; balloon 10 ml for diagnosis of neurogenic bladder. R103's Minimum Data Set (MDS) dated [DATE] documents R103 has indwelling catheter. R103's care plan documents in part R103 has indwelling (Foley) catheter and interventions include but not limited to EBP. R103's electronic health record (EHR) progress note titled Education Note entered by V5 dated 08/21/25 at 10:44 documents in part EBP and hand washing education given to (R103's son) and verbalized understanding the reason of EBP as well of the importance of hand washing. There were no other education notes found in R103's EHR progress note section indicating education on EBP guidelines were provided to any of R103's family members between the dated 07/29/22 to 08/20/25. Facility provided policy titled, Contact Precautions dated 05/2022 which documents in part, contact precautions are intended to prevent transmission of infectious agents, like MDROs that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room and transmission occurs by contaminated hands of staff. The single most effective means of reducing the potential transmission is hand antisepsis before and after contact with residents. Facility provided copy of Contact Precaution sign from the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents in part, everyone must clean their hands, including before entering and when leaving the room and providers and staff must also put on gloves before room entry and put on gown before room entry. Facility provided policy titled, Enhanced Barrier Precautions (EBP) dated 05/2022 which documents in part, this precaution is in use in long term care facilities to prevent the spread of novel or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 18 of 20 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 08/22/2025 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 0880 MDRO infections and everyone must clean their hands before entering and when leaving a room. Level of Harm - Minimal harm or potential for actual harm Facility provided copy of Enhanced Barrier Precaution sign from the U.S. Department of Health and Human Services Center for Disease Control and Prevention which documents in part, everyone must clean their hands, including before entering and when leaving the room. Residents Affected - Many Findings Include: On 8/19/25 at 12:08 PM, surveyor observed V35 (Laundry Aide) on the second floor delivering clean residents' clothing in an uncovered cart. On 8/20/25 at 11:14 AM, V5 stated that Dirty linens are bagged, and have a chute. Clean clothing and clean linen come from the lower level to the floor. The laundry person put them in the cart and transport them on the floors. The cart should be closed or covered and transport clean personal clothing directly to the floors and to the resident's rooms. Linens are from the basement to the floors the laundry will transfer to the big cart. Clean carts should almost be closed. To prevent cross-contamination and keep them clean free from germs or dirt. On 8/21/25 at 10:07 AM, surveyor did laundry service walk-through with V34 (Maintenance Director) and found a large, gray bin filled with linens and residents' gown not contained in bags and the bin was not covered. On 8/21/25 at 10:21 AM, V5 stated that all soiled linens in the soiled room should be bagged and covered due to risk for cross contamination and risk for infection. V5 stated that the residents and staff could potentially be affected. V5 stated the staff works with the residents so everyone in the facility could potentially be affected. The staff could get sick, and the residents could get sick. The facility's LINEN and LAUNDRY policy and procedures dated 5/22 documents in part: Personnel to bag contaminated linen at the point of use, and not sorting or pre-rinsing in resident care areas. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Place any linen saturated with blood or body fluids into a bag before placing it into the hamper. Clean linen will be transported from the laundry to the linen room in a clean, covered cart with a solid bottom. Linen is covered during transport to prevent contamination while being moved through the facility. Linen must remain covered at all times until it is placed into the residents' room. The facility's residents' roster dated 8/19/25 documents a total of 202 residents residing in the facility. ---------------------------Findings include: R20's 'Order Summary Report' documents in part active wound orders to R20's left and right ischium. There is also an order for Enhanced Barrier Precaution (wound) every shift for Wound Care. Order active since 8/06/2025. R20's 'Care Plan Report' documents in part skin issues, wounds, and risk for impaired skin integrity (page 10, 28-32); however, it does not contain a focus for EBP (Enhanced Barrier Precautions) related to wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 19 of 20 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 08/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm On 8/19/2025 at 11:40 AM, there was no EBP signage on R20's door or wall outside of the room. R20 stated having wounds that require treatment by the nurses. On 8/19/2025 at 2:53 PM, V5 (Infection Preventionist) stated any resident with an open area such as a wound should be on EBP. Residents Affected - Many On 8/20/2025 at 1:50 PM, R20's room remained without EBP signage. V27 (Laundry Aide/Housekeeping) was in the room cleaning R20's area. V27 stated [V27] did not know whether R20 was on EBP or not. V27 stated there's no sign. On 8/20/2025 at 1:52 PM, V12 (Nurse) stated R20 is on EBP and should have a sign on the door to inform staff. Facility's 5/2022 'Enhanced Barrier Protection' policy documents in part: This precaution is for use in long term care facilities to prevent the spread of novel or [Multi-Drug Resistant Organism] infections. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required [Personal Protective Equipment] (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. ----------------------Findings include: On 08/19/2025 at 11:48 AM at the hallway near entrance of dining room a cooler colored blue and white was seen with resident scooping ice cubes from inside the cooler with plastic scooper. Then putting ice cubes inside plastic pitcher. V28 (Certified Nursing Assistant) after seeing resident stated that residents do not need to do that taking ice from the cooler. Scooper was then placed at the bottom of the cart where on top the cart, cooler was located. Scooper was uncovered and exposed to environment. On 08/20/2025 at 3:20 PM V5 (Infection Preventionist) stated that it is the staff that needs to scoop the ice. But because some residents are highly independent, they (residents) scoop ice cubes in the cooler. V5 said, we try not for them to do that because contamination happens. Scooper supposed to have a little bin and needs to have a top cover. There is cooler on each floor and only residents on that floor can use ice cubes in the cooler. Infection Control Plan dated 06/2022: Policy and Practices, this facility's infection control policies and practices are intended to facilitate maintaining, a safe, sanitary and comfortable environment and help prevent and manage transmission of diseases and infections. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and general public. The objective of our infection control policies and practices to provide guidance to ensure a safe, sanitary food operation to prevent food borne illness. To provide guidance to ensure safe, sanitary water supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145792 If continuation sheet Page 20 of 20