Pavilion of South Shore

Inspectors wroteBased on interview and record review, the facility failed to ensure physician-ordered laboratory tests were completed and followed up in a timely manner for one resident (R2) out of three residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family member in a timely manner when a change in condition occurred. This failure affected 1 resident (R1) reviewed for changes in condition.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of misappropriation of property for one (R1) out of three residents reviewed for misappropriation of resident property in a total sample of three residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention program and conduct a thorough investigation for one (R1) out of three residents reviewed for misappropriation of property in a total sample of three residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1-Perform proper hand hygiene when passing food tray, after handling soiled dishes, and before handling clean dishes. 2- Properly label perishable items inside the walk-in fridge 3- Prevent personal food items inside the walk-in fridge. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (1) dispose of kitchen garbage properly in a contained dumpster, (2) failed to keep the dumpster area clean free of debris, the garbage area was not maintained in a sanitary condition to prevent harborage and feeding of pest. These failures could affect all 111 residents that reside in the facility. Findings Include: On 2/5/25 at 9:16 AM, During the initial facility tour, with V20 (Director of Maintenance) and V19 (Assistant Maintenance) observed the outside dumpster area where kitchen garbage is disposed with the large dumpsters uncovered with lids. All around the dumpsters were food garbage, papers, and foul odors. V19 stated that the dumpster is open, but it should be covered. V20 stated that the uncovered plastic bags in the dumpster are from the kitchen, and the housekeeping. [...]

Inspectors wroteBased on observations, interviews and record review, the facility [A] failed to ensure shared equipment were cleaned and decontaminated between each use for 4 [R61, R68, R72, R263] and [B] failed to follow their infection control procedures to post Enhanced Barrier Precautions (EBP) signage outside 1 [R39's room] resident with active right subclavian perma catheter for dialysis in a sample of 23 residents. Findings Include: On 2/4/25 at 9:42AM, V8 obtained R61's blood pressure [103/69] with a manual blood pressure device placed on R61's bed linen, that was on top of the medication cart. After use, V8 then placed the manual blood pressure device back on top the medication cart and did not sanitize the blood pressure device. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy to ensure that call lights are within easy reach for two (R25, and R58) residents out of 8 residents reviewed for call lights in a sample of 23. Findings Include: 1. R25's face sheet shows R25 is an [AGE] year-old male. R25's electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with diagnoses not limited to: Chronic obstructive pulmonary disease, age related nuclear cataract, left eye, blindness left eye, history of falling, presence of pacemaker, wedge compression fracture of third lumbar vertebra, anxiety disorder, and atrial fibrillation. 2. R58's face sheet shows R58 is a [AGE] year-old male. R58's electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure code status should be consistent with plan of care and physician order for one (R29) resident reviewed for advance directives in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their peripheral inserted central catheter line dressing change policy, [A] failed change the line catheter dressing when not intact or compromised in any way, [B] failed to label the dressing with date or time, and [C] failed to enter physician orders of dressing changes and intravenous flush orders for one [R61] resident in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow plan of care and physician order to apply hand roll or splint on right hand for 1 (R29) resident. This failure could potentially affect 1 (R29) resident reviewed for range of motion in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that smoking materials (cigarette and lighters) were kept by staff for safety. This failure could potentially affect 3 (R28, R84, R93) residents reviewed for smoking in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen use and no smoking signage was posted on a resident's (R213) door who's on continuous oxygen, failed to date humidifier bottle for oxygen concentrator and nebulizer mask for 1 (R71) resident, and failed to follow physician order for oxygen liter flow and provide humidification for continuous use of oxygen for 1 (R28) resident out of 3 residents reviewed for respiratory care in a final sample of 23. Findings Include: On 2/04/25 at 11:24 AM, R213's sleeping in bed observed on oxygen at 3 liters per minutes (LPM) via nasal cannula. Surveyor did not observe oxygen in use and no smoking signage posted on R213's door or over R213's bed. On 2/05/25 at 11:22 AM, R213's lying in bed alert and able to verbalize needs. R213 was using oxygen via nasal cannula set to 3 LPM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the risk versus benefits of using a bed rail and review them with the resident prior use, and failed to implement person-centered comprehensive care plan addressing the use of the bed rail. These failures have the potential to affect 1 (R213) out of 4 residents reviewed for bed rails in a final sample of 23. Findings Include: On two separate occasions on 2/04/25 at 11:24 AM and on 2/05/25 at 11:22 AM, R213 was observed resting in bed and noted with one full bed rail up on the right side of R213's bed. On 2/05/25 at 1:50 PM, interviewed V14 (Restorative Licensed Practical Nurse) and stated that restorative does the residents' bed rail assessments, and they need to be completed before using the bed rail. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess eligibility and offer pneumococcal vaccine to three (R39, R48, R72) of five residents reviewed for pneumococcal immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the Pneumococcal vaccinations in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to follow facility's policy and procedure, the facility failed to assess eligibility and offer covid-19 vaccine to three (R39, R48, R72) of five residents reviewed for covid-19 immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the covid 19 vaccinations in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call lights of residents are accessible as stated in the care plans. This failure has the potential to affect 2 residents ( R1 and R2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the fall prevention interventions as stated in the care plans for residents with diagnoses of Dementia who are also at risk for falls. This failure has the potential to affect two residents (R3 and R4) reviewed for proper footwear as a fall prevention intervention.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three residents (R1) was free from abuse. This failure affected R1 who was attacked by another resident R2. As a result, R1 sustained a human bite, had to get a tetanus shot and was treated with antibiotics as a prophylactic for infection. this as the potential to affect all 41-resident residing on the 2nd floor.

Inspectors wroteBased on interview and record review the facility failed to develop and implement appropriate measures to ensure that adequate supervision is provided to two of three residents (R1 and R2) reviewed for supervision. This failure affected R1 and R2 who had an altercation that resulted in R1 having a human bite. R1 had to get a tetanus shot and was treated with antibiotics as a prophylactic for infection. this has the potential to affect all 41-resident residing on the 2nd floor.

Inspectors wroteBased on interview and record review the facility failed to provide transportation for a resident (R1) who required daily methadone clinic visits. This failure affected one of three residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to maintain acceptable parameters of nutritional status as evidenced by an unrecognized significant weight loss, failed to serve food desired by a resident and failed to care plan weight loss for one resident (R57) in a sample of 26 total residents. This failure resulted in R57 experiencing a 17% weight loss that was not recognized and addressed by the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) discard expired and/or rotten foods, c.) keep food storage areas clean, d.) conduct hand washing in between handling dirty and clean plateware/equipment. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to (a) ensure there was signage outside of the resident's (R74) room indicating Enhanced Barrier Precaution (EBP); (b) provide readily available personal protective equipment (PPE) supplies outside of the resident's (R74) room; (c) use PPE in isolation rooms (R74, R28, R85, R410); (d) maintain infection control practices during medication administration (R4, R93, R105); (e) ensure a resident's (R85) urinary catheter bag remained off the floor; and (f) contain soiled linens in sealed bags during transport. This has the potential to affect 111 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of professional practice to maintain resident dignity by standing over four residents (R7, R22, R57, R91) during feeding assistance out of a sample of 26 total residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow facility policy by not providing residents going to dialysis during mealtimes with a sack lunch for four (R29, R40, R45, R101) out of four residents reviewed for dialysis services in a sample of 26.

Inspectors wroteBased on observations, interviews, and record review the facility [A] failed to label individual resident's insulin medications with an open date, [B] failed to dispose expired insulin, [C] failed to refrigerate unopened insulin in 3 of 5 medication carts reviewed for medication storage and labeling in a sample of 26. On 4/16/23 at 9:22 AM, V18 [Licensed Practical Nurse] and surveyor conducted inventory of the third-floor medication cart, observed the following: R72's [1] Open Novolog Flex Pen was opened and used, no open or expiration date. [2] Open Lantus insulin pen with an open date of 3/14/24, expiration date of 4/12/24, and [3] Open [NAME] pen with no open date. R72's physician orders: 12/14/23-Novolog Solution 100 units/ml, inject 10units three times per day. 9/6/22-Lantus Solution 100 unit/ml, inject 25 units at bedtime. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to determine self-administration of medication was appropriate for three (R5, R57, R69) out of three residents observed with medication at bed side in a sample of 26. Findings Include: On 04/16/24 at 10:41 AM, surveyor entered R69's room and observed one medication in a medication cup on R69's bed side table. R69 stated the nurse left the medication on R69's table this morning, but R69 does not want to take the medication. At 10:45 AM, R69 triggered the call light, and V30 (Registered Nurse/RN) entered R69's room, V30 picked up the medication, V30 identified the medication as Colace 100 MG capsule administered at 9:00 AM. V30 stated V30 usually stay with R69 to ask if R69 wants the medication, but V30 did not ask R69 today because V30 went out of R69 to attend to other residents. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to place a resident's (R410) call light in a position that allowed the resident to utilize it for one out of a total sample of 26 residents reviewed for call lights.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattress was available for 1 (R74) resident with Stage IV pressure ulcer and failed to ensure the low air loss mattress was in the correct setting for 1 (R56) resident. These failures affected 2 (R56 and R74) of 2 residents reviewed for pressure ulcer in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the left-hand splint and left AFO (Ankle Foot Orthosis) were in place. These failures affected 2 (R38 and R54) residents reviewed for limited range of motion in a sample of 26.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure fall precautions were in place for a resident (R18) at risk for falls for one out of a total sample of 26 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to place oxygen cannula tubing in a bag when not in use for one (R103) resident of three residents reviewed for respiratory care in a sample of 26.

Inspectors wroteBased on interviews and record reviews the facility failed to obtain medication consents and care plan for the use of an antidepressant for R85, in a total sample of 26.

Inspectors wroteBased on interview and record review the facility failed to adequately supervise 1 of 3 residents (R2) reviewed for elopement. This failure resulted in R2 leaving the facility unsupervised through an exit door. R2 was found hours later by the police, taken to the hospital by EMS (Emergency Medical Services), and admitted with a diagnosis of hypothermia. This situation was identified as an immediate jeopardy. The Administrator was notified and presented with the immediate jeopardy template on [DATE] at 11:24 AM. The immediate jeopardy began on [DATE] and removed on [DATE]. The facility presented an acceptable removal plan on [DATE]. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan. Findings Include: On [DATE] R2 was observed to be missing from the facility-by-facility staff. [...]

Inspectors wroteBased on interviews and record review the facility staff failed to report an elopement and unusual occurance (unscheduled hospitalization) to the Illinois Department of Public Health for 1 (R2) of 3 residents reviewed for reporting. R2 eloped from the facility, was located with the assistance of the local police department , taken to local the hospital and recieved treatment for hypothermia. The facility also failed to follow the facility policies for reporting an accident, incident or unusual occurrence. This deficient practice was evidenced by the following: Findings Include: On [DATE] R2 was observed to be missing from the facility-by-facility staff. R2 was not found after a facility and community search was conducted by the facility. Per facility documentation the Chicago Police department was notified and participated in the community search. [...]

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that 1 (R3) of 4 residents received treatment and care in accordance with the professional standards of practice, according to the side rail assessment, and the comprehensive person-centered care plan, as evidenced by: Findings Include: R3 has diagnosis not limited to Paraplegia, Asthma, Epilepsy, Insomnia, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Malignant Neoplasm of Colon, Neuromuscular Dysfunction of Bladder, Schizoaffective Disorder and Long Term (Current) Use of Anticoagulants. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Assist Rail Screening dated 10/23/23 document in part: D. Recommendation: This facility uses assist rails which may be in a horizontal or vertical position. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected two residents (R1 and R2) of seven residents reviewed for quality of care and administration of prescribed medications.

Inspectors wroteBased on interviews and record review, that facility failed to ensure that one resident (R3) was free from pain, after a suspected unwitnessed fall. This failure affected one of 7 residents reviewed for pain management.

Inspectors wroteBased on observation, interview and record review the facility failed to discard food items stored in the walk-in refrigerator and dry storage room by the use-by date; failed to follow proper food storage practices and labeling of food to prevent food-borne illnesses; failed to don a hairnet while in the kitchen; failed to ensure sanitizing buckets had the required amount of sanitizing solution needed for proper sanitizing per the manufacturer's recommendation; failed to ensure cleanliness of kitchen and storage refrigerator and failed to isolate dented cans from non-dented cans to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 113 residents receiving an oral diet in the facility.

Inspectors wroteBased on interview and record review, the facility failed to track, and ensure 100% of staff were vaccinated with Covid vaccine to help prevent the spread of Covid-19 as required by CDC (Centers for Disease Control and Prevention). These failures have the potential to affect all 114 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident room identifier outside of 11 resident rooms on the first floor. This failure has the potential to affect all 22 residents residing in the affected rooms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive shaving. This affects four residents (R13, R20, R24, and R106) out of 45 residents reviewed for ADL care and grooming.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications at the end of the shift, failed to maintain an accurate account of controlled medication for 1 (R22) resident, and failed to document administration of as needed controlled medication for 1 (R22) resident. These failures affected 1 resident (R22) reviewed for medication labeling and storage and have the potential to affect all 35 residents in the 3rd floor.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of loose pills in the bottom of 1st floor medication cart, failed to remove expired house stock medications from 1st floor medication cart, and failed to remove expired insulin for 2 residents (R4, R88) residing on the 3rd floor receiving insulin from 3rd floor medication cart. This failure has the potential to affect all 16 residents receiving medication from the 1st floor medication cart and 35 residents receiving medication from the 3rd floor medication cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to post isolation signs on the door of positive covid residents rooms; failed to have isolation equipment available prior to entering an isolation room, failed to ensure that staff don PPE (Personal Protective Equipment) face mask covering the nose and the mouth for prevention and control of Covid-19, and failed to change and date oxygen tubing and humidification bottle in an effort to prevent the spread of infectious microorganisms including COVID-19. These failures affected five resident (R16, R23, R72, R 213, and R214) and has the potential to affect all 39 residents on the second floor and all 36 residents on the third floor in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure facility handrail on the first floor was firmly secured to the wall. This failure has the potential to affect all 38 residents residing on the 1st floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light was within reach for two residents (R10, R28). This failure has the potential to affect two residents (R10, R28) in a sample of 45 residents.

Inspectors wroteBased on interview and record review the facility failed to provide the monthly trust fund allowance to one resident (R77) out of a sample of 45 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions as per resident care plan and failed to provide and document wound treatments as ordered for one resident (R14) with a Stage III pressure ulcer in the total sample of 45 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ordered oral nutritional supplements, for one resident (R213) reviewed for nutrition in a sample size of 45 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' call device was functioning to allow resident to call for staff assistance. This failure affected 1 resident (R28) reviewed for functioning resident call device in a total sample of 45 residents.