BUCKINGHAM PAVILION
For profit - Corporation
235 Beds
Independent
Data: November 2025
Trust Grade
63/100
#122 of 665 in IL
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Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Buckingham Pavilion in Chicago has a Trust Grade of C+, indicating that it is slightly above average but not exceptional. It ranks #122 out of 665 facilities in Illinois, placing it in the top half, and #42 out of 201 in Cook County, meaning there are only a few local options that are better. The facility is showing improvement, as it reduced its issues from 20 in 2023 to 9 in 2024. However, staffing is a concern, rated at 2 out of 5 stars with a high turnover rate of 57%, which is above the state average. Recently, there were specific incidents noted during inspections, such as staff not using gloves while handling food and failing to properly store food items, which could pose health risks to residents. Additionally, expired food was found in the kitchen, which raises concerns about food safety practices. On a positive note, the facility provides more RN coverage than 80% of Illinois facilities, which can help catch potential problems early. Overall, while Buckingham Pavilion has some strengths, particularly in RN coverage, its staffing issues and recent inspection findings suggest that families should carefully consider these factors when researching care for their loved ones.
- Trust Score
- C+
- In Illinois
- #122/665
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $9,750 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 18%
No red flags
20 → 9 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 20 issues
2024: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 57%
10pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $9,750
Below median ($33,413)
Minor penalties assessed
Staff turnover is elevated (57%)
9 points above Illinois average of 48%
The Ugly 29 deficiencies on record
Nov 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to follow their policy in providing privacy to 1 out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to follow their policy in providing privacy to 1 out of 1 resident (R94) when providing bedside care for a total sample of 23 residents reviewed.
Findings include:
R94 is [AGE] years old, admitted in the facility on 02/06/2024. R94 medical diagnosis includes malignant neoplasm of the brain.
On 11/12/2024 at 11:51 AM, while passing the hallway, the door of R94's room was open visually able to see the R94's bed elevated without clothes from waist down. V15 (Certified Nursing Assistant) was seen taking linen on the cart located at the hallway. V15 stated that she was doing patient care as R94 was calling for V15.
On 11/12/2024 at 12:29 PM, after finishing bedside care V15 was asked why the door was opened during bedside care with R94? V15 stated that she was taking some things in her linen cart when she opened the door. V15 stated that R94's gown may not be placed on her that could have exposed her visually from the hallway. V15 was asked why privacy curtain was not used? V15 replied that she forgot to use the curtain. V15 stated that putting herself to R94 situation being exposed, she will not feel well and would feel bad that she was exposed. V15 stated the importance of using privacy curtain when taking residents. V15 stated that R94 does not have clothing waist down because R94 had a bowel movement.
On 11/13/2024 at 12:51 PM, V1 (Administrator) stated that as far as practicable privacy of residents that are exposed needs to be maintained by using privacy curtain and closing the door. This applies to other residents inside the room and people passing in the hallway.
On 11/14/2024 at 10:55 AM, V3 (Wound Coordinator/Acting Director of Nursing/Registered Nurse) stated that privacy curtain is used when a resident is exposed like when changing diaper. The use of privacy curtain also applies to a nursing procedure like performing G Tube (stomach feeding tube) care. When a resident is exposed, not only does the resident lose their privacy but also their dignity. V3 said that she will be embarrassed if she will be on a similar situation as being exposed.
Privacy policy dated 09/16/2024, reads:
Resident rooms shall be designated and equipped for adequate nursing care, comfort, and privacy of residents. Bedrooms shall be equipped to assure full visual privacy for each resident. Provide each resident with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations, interview and review of records, facility failed to follow a resident's care plan to ensure the call light was within reach for 1 (R98) out of three residents reviewed for call ...
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Based on observations, interview and review of records, facility failed to follow a resident's care plan to ensure the call light was within reach for 1 (R98) out of three residents reviewed for call lights in a sample of 23.
Findings include:
On 11/12/2024 at 11:41 AM, surveyor observed R98 lying in bed. Surveyor observed R98's call light was on the fall mat and not within reach of the resident. R98 stated that she doesn't even know where her call light is at.
On 11/12/2024 at 11:45 AM, surveyor asked V5 (Registered Nurse) to come into R98's room. V5 came in and saw R98's call light on the floor mat. Surveyor asked V5 if R98 can reach her call light. V5 stated that R98 cannot reach her call light safely. Surveyor observed V5 tie R98's call to her side rale.
On 11/14/24 at 11:00 AM, V3 (Wound Care Nurse/Registered Nurse) stated she is the currently the acting director of nursing (DON) and helping out V2 (Director of Nursing) because she is out sick. V3 stated call lights are supposed to be within the reach of the residents. V3 stated that if the call lights are not within reach of the residents, care will not be given on time and the resident will have a risk of falling.
R98's face sheet documents in part: R98 has a diagnosis of history of falling.
R98's care plan documents in part: Reinforce to use call light when needing assistance. Place call light within reach.
Facility's call light policy (12/5/2019) documents in part: It is the policy of the facility to maintain a call light system for residents to summon staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide privacy and confidentiality for three (R37, R44, R82) resident's personal medication administration record.
Finding in...
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Based on observation, interview, and record review the facility failed to provide privacy and confidentiality for three (R37, R44, R82) resident's personal medication administration record.
Finding include,
On 11/12/24 at 9:25 AM, surveyor observed V9 (Registered Nurse) administer R37, R44, and R82's medications.
On 11/12/24, at 9:29 AM, V9 prepared R37's medications. V9 stated, Let me go see if R37 wants any medication for constipation. At 9:32 AM, V9 walked away from the medication cart with the computer screen open with R37's personal medication on the lap top screen. V9 returned to the medication cart, then left the cart again to answer the phone at the end of the hallway, the computer screen was open with R37's personal medical information exposed.
On 11/12/24, at 9:56 AM, V9 prepared R44's morning medications. V9 walked away from the medication cart to administered R44's medications and left the computer screen open with R44's personal information exposed.
On 11/12/24, at 10:01 AM, V9 prepared R82's morning medications. V9 walked away from the medication cart to administer R82's medications and left the computer screen open with R82's personal information exposed.
On 11/12/24, at 10:20 AM, V9 stated, I forgot to lock the computer screen, or I could have minimized the screen so no one would have been able to visualize the residents' personal information.
On 11/14/24, at 10:30 AM, V3 (Assistant Director of Nursing/Wound Care Nurse) stated, The nurses should lock their computer screens before walking away to provide the resident privacy. If the computer screen is unlocked, anyone, residents, and visitors can see the resident personal information.
Policy-Documents in part:
Resident Rights
-You have the right to privacy over your personal and clinical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record reviews, facility failed to follow their policy to ensure routine wellbeing checks are done for 1 (R45) out of three residents reviewed for activities of d...
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Based on observations, interviews and record reviews, facility failed to follow their policy to ensure routine wellbeing checks are done for 1 (R45) out of three residents reviewed for activities of daily living (ADL) care in sample of 23.
Findings include:
On 11/12/2024 at 11:21 AM, surveyor observed R45 laying on her back. There was a foul odor coming from R45. R45 stated that she hasn't been changed.
On 11/12/2024 at 12:21 PM, surveyor observed V7 (Certified Nursing Assistant) go into R45's room and drop of her lunch meal tray and walk out. R45 was still laying on her back.
On 11/12/2024 at 1:01 PM, surveyor observed V7 go into R45 to feed the resident. V7 did not change or turn the resident. R45 was still laying on her back.
On 11/12/2024 at 1:30 PM, R45 was still not cleaned up, turned or repositioned. R45 was laying on her back.
On 11/12/2024 at 1:35 PM, V7 stated that the last time she changed or repositioned was at 10:00 AM. V7 stated that she is supposed to check on residents and reposition them every two hours.
On 11/12/2024 at 1:45 PM, surveyor observed R45's wound. Wound on sacrum is dry and closed.
On 11/14/2024 at 11:08 AM, V3 (Wound Care Nurse/Registered Nurse) stated that their policy for wellbeing checks states 'nursing staff shall perform routine checks throughout their shift'. V3 stated that routine checks are every two hours. They are supposed to check their mental status, positioning, and if they need anything. If they are dependent and non-verbal we check if they have soiled themselves and we have to change them at least every two hours. For someone who is dependent and non-verbal, if they are not checked every two hours, they may not get help in a timely manner. If there is a medical emergency, we may not be able to respond on time. V3 stated that R45 has a moisture associate wound which is like a skin tear. V3 stated that if R45 is not checked on frequently then her moisture associated rash or skin tear can get worse.
R45's care plan documents in part: R45 has urinary incontinence, fecal incontinence, open lesion moisture associated. Assist with hygiene and general skin care. Keep skin clean and dry. Establish consistent routine checks.
R45's physician order sheet documents in part: perineal (diaper dermatitis), frequency: twice a day. Clean with normal saline. Treatment: Zinc oxide/vitamin A&D ointment.
R45's Treatment Administration Record for 10/2024 documents in part: perineal (diaper dermatitis), frequency: twice a day. Clean with normal saline. Treatment: Zinc oxide/vitamin A&D ointment.
R45's MDS Section H, Bowel and Bladder (10/04/2024) documents in part: R45 always has urinary and bowel incontinence.
R45's MDS Section GG, Functional Abilities (10/04/2024) documents in part: when it comes to toileting hygiene, R45 is completely dependent where the helper does all the effort.
Facility Wellbeing checks (08/19/2016) documents in part: Nursing staff shall perform routine checks throughout their shift and ensure that any identified needs are addressed in a timely fashion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to follow their enteral tube feeding via pump policy to ensure 1 (R21) resident's enteral nutrition bottles were labeled befor...
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Based on observations, interviews, and record reviews the facility failed to follow their enteral tube feeding via pump policy to ensure 1 (R21) resident's enteral nutrition bottles were labeled before administration in a sample of 23 reviewed for enteral tube feeding.
Findings include,
R21's clinical record document in part, R21 was admitted with the following medical diagnosis Corticobasal degeneration, Gastro-esophageal reflux disease with esophagitis, pneumonitis due to inhalation of other solids and liquids, dysphagia, gastrostomy status, secondary hypertension, anemia, inflammatory disease of prostate, and chronic obstructive pulmonary disease.
Physician orders: 11/11/24: Tube feeding: (brand name of feeding solution) 35m/hour continuous via gastric tube. Keep head of bed elevated 30-45 degrees. Assess feeding tube placement, flush with 30 ML (milliliters) before and after medication administration. Monitor for signs of infection on the insertion site. Change gastric tube site dressing with dry 4x4 gauze after site is cleaned with saline gauze.
On 11/12/24 at 11:11 AM, surveyor and V6 (Licensed Practical Nurse) observed R21 resting in bed with his gastric tube infusing. The infusing bottle of gastric feeding solution did not bear a label. The feeding bottle did not have the following information: name of the feeding solution, name of resident, date, start time, or rate. There was a second bottle hanging with a clean substance in the bottle, no label or resident's information was present.
On 11/12/24 at 11:15 AM, V6 (Licensed Practical Nurse) stated, When I came into work R21's gastric feeding tube was already up and infusing. R21 was re-admitted back to the facility yesterday on 11/11/24. The night nurse did not have the feeding bottle of R21's ordered solution available in the one-liter bottle. We did have the formula in the small 8-ounce cartons. The night nurse and I retrieved another feeding one-liter bottle and poured out feeding solution poured in the small eight-ounce cartons of the ordered feeding solution and pulled of the feeding label because the label was not the correct feeding solution. The name of the feeding solution, residents name, date, and time the solution was started, and rate should be on the feeding bottle. The second bottle hanging is R21's water flush bottle. The bottle does not have any information on the bottle. The bottle should have R21's name, date, time, amount of water flush and rate on the bottle. I forgot to place the label on the water bottle.
On 1/19/24 at 12:10 PM V3 (Assistant Director of Nursing/Wound Care Nurse) stated, All gastric feeding bottles and water bottles are labeled with the resident's name, room number, date opened, time opened, formula type, rate flow, and water flow rates. If the feeding and water bottles are not labeled, the resident could potentially receive old, spoiled formula and water. The next nurse would not know when or how much feeding formula or water the resident received. That could potentially cause harm to the resident such as weight loss, infection, or wrong formula given.
Policy Documents in part:
Feeding Tube Administration dated 8/9/24.
Administration the prescribed enteral nutrition formula unless approved by the dietician or physician. The type, volume, and rate will be determined by the attending physician or dietitian based on the patient's nutritional requirements.
Label the formula with patient's name, date, start time rate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to provide dental services for a resident who has di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of records the facility failed to provide dental services for a resident who has difficulty chewing due to lack of upper teeth for 1 out of 1 resident (R56) for a total sample of 23 residents.
Findings include:
R56 is [AGE] years old, admitted in the facility on 12/16/2023, with diagnosis of chronic kidney disease (stage 4), dependence on renal dialysis. R56 cognition was intact during conversation. R56 can express his thought well.
On 11/12/2024 at 11:55 AM, R56 stated that he cannot chew some food because his teeth were extracted prior to coming in the facility two (2) years ago. Until now he does not have any dentures. R56 opened his mouth and does not have any upper teeth visually seen. R56 stated that he has hard time chewing meat because of lack of dentures.
On 11/14/2024 at 10:23 AM, V13 (Registered Nurse) stated that R56 does not have dentures for eating. He (V13) does not know if R56 was having difficulty of eating or does not have upper teeth.
On 11/14/2024 at 10:39 AM, V3 (Wound Coordinator/Acting Director of Nursing/Registered Nurse) stated that she was not sure if R56 has dentures. Residents that don't have upper or lower teeth need to have dental services. V3 stated, As far as I know if residents have problem on chewing, we send them to the dentist. V3 stated that she will review R56's clinical record to check if R56 was seen by the dentist. V3 after review, stated that R56's clinical record does not document any dental care.
Dental Services policy dated 08/08/2019, reads: Facility shall assist residents in obtaining routine and 24-hour emergency dental care. Facility shall provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination and failed to document resident education for the vaccinations for 3 resi...
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Based on interview and record review, facility failed to follow their policy to provide influenza and pneumococcal vaccination and failed to document resident education for the vaccinations for 3 residents (R43, R45, and R98) out of 5 residents reviewed for vaccinations in a sample of 23.
Findings include:
On 11/13/2024 at 11:19 AM, V4 (Quality Assurance/Infection Preventionist) and surveyor reviewed the immunization status for residents. V4 stated all the immunization records, consent and education provided are documented in the resident's electronic health record. V4 stated that R98 refused their influenza immunization. Surveyor asked V4 if R98 had received education for the influenza vaccine. V4 stated yes but was unable to provide documentation showing influenza education was provided to R98. V4 also stated she did not offer R43 his pneumococcal vaccination because she has not gotten to it yet. V4 was unable to provide a history of R43's pneumococcal vaccination nor any consent or education documentation. Lastly V4 stated that R45 refused her pneumococcal vaccine but was unable to provide any consent or documentation on education for R45 on the benefits of pneumococcal vaccine.
On 11/14/2024, at 11:50 AM, V3 (Wound Care Nurse/Registered Nurse) stated, that the purpose of flu and pneumococcal vaccines are to prevent residents from having the flu or pneumonia. If vaccination is not offered, then residents will have a higher risk of catching the flu or pneumonia. Before any vaccination, we provide education and consent. The purpose of education of the vaccination is to help the resident be informed of the benefits and side effects of the vaccination and make an informed decision. If education is not provided, they cannot make an informed decision.
R98's immunization record documents in part: No influenza vaccine administered. No documentation of education provided.
R43's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent form provided.
R45's immunization record documents in part: No pneumococcal vaccine administered. No documentation of education or consent form provided.
Facility's Pneumococcal Vaccine policy (11/28/2017) documents in part: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series. Before receiving pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Residents/representatives have the right to refuse vaccination if refused appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination.
Facility's Influenza Vaccine policy (11/28/2021) documents in part: All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Prior to the vaccination the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine form and placed in the residence medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disorder for Preadmission Screening and Resident Review (PASRR) to the appropriate state-designated authority. This failure affects four (R22, R32, R47, R82) residents in a total sample of 23 residents reviewed.
Findings include:
On 11/13/2024 at 3:19 PM, V8 (Admissions Director) stated all eligible residents should receive a PASARR screening upon admission. V8 stated the hospital is responsible for completing the Level 1 Pre-admission Screening and Resident Review (PASARR) prior to a resident's admission to the facility. V8 stated the facility ensures the resident has a Level 1 PASARR prior to admission and the facility is responsible for ensuring that the resident PASARR screening are accurate upon admission into the facility. V8 stated the facility no longer utilizes the OBRA/Omnibus Budget Reconciliation Act screening for the PASARR screenings. V8 stated the facility staff is responsible for inputting resident data into the PASARR screening program. V8 stated based on resident medical records information that is input, a PASARR screening determination is generated in the screening program. V8 stated information such as mental health diagnoses, demographics, and medications are input into the screening program. V8 stated the PASARR determination is then referred to the social services department. V8 stated if information is inaccurately input into the screening program, this could result in an inaccurate PASARR screening report. V8 stated the purpose of the PASARR screening is to ensure the resident's mental health level of care is provided. V8 stated she is unsure of how often residents need to be screened for PASARR screenings. V8 stated she is not sure if a resident should be screened for another PASARR screening if they have a new diagnosis of a mental health condition while residing in the facility. V8 stated the DON/determination of needs score is also provided on the PASARR screening. V8 stated the DON score determines whether the resident is appropriate for the facility.
1.) R22's Face sheet documents that R22 is an [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia.
R22's PASARR screening titled OBRA I Initial Screening is dated 01/07/2012. OBRA I screening documents that there is no reasonable basis for suspecting DD/Developmental Disability or MI/ Mental Illness.
There is no documentation to show that R22 was screened for a new Level I PASARR screening or a Level 2 PASARR screening.
2.) R82's Face sheet documents that R82 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia, bipolar disorder, and depressive episodes.
R82's PASARR screening titled Notice of PASRR Level I Screen Outcome dated 11/10/2022, documents that a Level II screening is not required due to no SMI (severe mental illness)/ID (intellectual disability).
R82's PASARR screening does not document that R82's diagnoses of schizophrenia and bipolar disorder were included as mental health diagnoses on R82's screening that was submitted to the screening agency.
3.) R47's Face sheet documents that R47 is a [AGE] year-old female admitted to the facility on [DATE] who has diagnoses not limited to: schizoaffective disorder, bipolar type.
R47's PASARR screening titled Level I Notice of Determination dated 02/18/2020 documents that R47's PASARR referral type was a private hospital, the determination was withdrawn, and R47 does not require specialized services.
Facility document dated 08/08/2019, untitled, documents in part, Coordination includes- (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
4.) R32 is [AGE] years old, recent admission date 03/22/2021. R32 was diagnosed for vascular dementia and psychotic disorder with hallucination dated 10/19/2021 and major depressive disorder dated 12/06/2023. After request for Preadmission Screening and Resident Review (PASRR), facility submitted OBRA 1 - Interagency Certification of Screening Result with 01/27/2020 as date of screening.
On 11/13/2024 at 1:11 PM, V14 (Social Service Director) stated that she will coordinate with V8 (admission Director) if R32 has Preadmission Screening and Resident Review (PASRR) to the new system. R32 needs a new assessment because the OBRA 1 - Interagency Certification of Screening Result was dated 01/27/2020, after which R32 was diagnosed with psychotic disorder with hallucination on 10/19/2021.
On 11/13/2024 at 2:32 PM, V8 stated that all residents are required to have Preadmission Screening and Resident Review (PASRR) with the new system. It includes residents with mental illness or not. All residents do not use OBRA assessment anymore. Once Preadmission Screening and Resident Review (PASRR) level 2 is needed, it will be communicated to V14. Understanding the level of care needed related to mental health is important. It is also incorporated in the care plan. V8 stated to check if R32 has an updated Preadmission Screening and Resident Review (PASRR).
On 11/14/2024 at 9:32 AM, V1 (Administrator) stated that R32 does not have an updated Preadmission Screening and Resident Review (PASRR).
Preadmission screening for individuals with a mental disorder and individuals with intellectual disability policy dated 08/08/2024, reads: Facility will not admit any new resident with mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission.
2022 Illinois PASRR Redesign Understanding Your Changing Role in the PASRR Process Improvements to Preadmission Screening and Resident Review (PASRR) processes will be launched by the (state agency) and new partner, (name of company), on March 14, 2022. Updates include the implementation of a new web-based management system, (name of system). Changes are being made to the following processes:
o Submission of all PASRR Level I Screens
o Review of all PASRR Level I Screens
o Completion of PASRR Level II Assessments for Serious Mental Illness (SMI)
As of March 14, 2022, OBRA-I is being retired for Level I PASRR use. You will use the Level I Screening Tool found in (name of system).
MINOR
(C)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected most or all residents
Based on observations, interviews, and record review the facility failed to grant access of the residents' electronic health records to the survey team timely. These failures have the potential to aff...
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Based on observations, interviews, and record review the facility failed to grant access of the residents' electronic health records to the survey team timely. These failures have the potential to affect all 102 residents in determining a thorough review of residents' records to identify or rule out compliance of state and federal regulation.
Findings include:
On 11/12/2024 at 09:24 AM, V1 (Administrator) was informed and provided documents that the survey team needs to have complete access to resident's electronic health records, and it is important aspect of the survey process. V1 informed the survey team that facility needs to provide laptops because of the platform use by the facility in their electronic health record. At 11:20 AM at the nurse station, V1 was informed that survey team needs access to resident electronic record. At 2:43 PM, V1 was informed that team needs access to resident electronic record. V1 responded that laptops will be available beginning tomorrow (11/13/2024).
On 11/13/2024 at 9:20 AM, a follow up with V1 about the laptop to provide for the purpose of the survey. V1 stated that facility does not have available laptops since charger were missing. V1 stated that he will work on it, to provide the survey team with laptops. V1 was made aware of the importance of reviewing resident's records as part of survey process. At 12:59 PM, at the nurse's station, V1 was informed that electronic health record access does not give surveyors complete access. Pointing out that Face Sheets, Medication Administration Records (MAR), Treatment Administration Records (TAR) were not accessible. During this time, the survey team cannot deliberate and discuss privately any resident's record pertinent to the survey. Documentation of resident's record primarily, needs to be requested to V1 in order to access. At 1:02 PM, V1 was again informed that access granted to the survey team was not complete and the need to have privacy in reviewing residents' records without facility staff present.
On 11/14/2024 at 09:11 AM, V1 stated that for prospective purposes, the facility needs to procure laptops or provide desktops in the designated room for surveyors to use during survey process. But as of now it is too late to provide equipment due to the late stage of the survey. It was reiterated to V1 that review of the residents' record forms is an integral part of the survey process that will benefit the residents. The survey team was not provided equipment to access resident's record on the designated room assigned by facility for the whole duration of the survey process.
Medical Records policy dated 08/08/2019, reads:
In accordance with accepted professional standards and practices. Facility shall maintain medical records on each resident that are readily accessible for public health activities, health oversight activities and to avert a serious threat to health or safety.
Dec 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to provide care in a manner to promote dignity for two residents (R31, R50) reviewed for dignity in a total sample of 18 resid...
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Based on observations, interviews, and record reviews the facility failed to provide care in a manner to promote dignity for two residents (R31, R50) reviewed for dignity in a total sample of 18 residents.
Findings include:
1.) R31's comprehensive care plan dated 10/16/2023 documents in part that R31 requires one-to-one feeding assistance.
On 12/05/2023 at 12:33 PM, R31 sat in the dining room for lunch. V22 (Certified Nursing Assistant/CNA) stood on R31's right side feeding R31. V22 was not at eye level with R31.
On 12/07/2023 at 12:03 PM, V2 (Director of Nursing) stated staff must be respectful and be at the resident's eye level during feeding assistance.
On 12/07/2023 at 1:15 PM, V29 (CNA Supervisor) stated staff are supposed to sit next to the residents when providing feeding assistance. Staff should not stand over the residents.
Reviewed facility's Assistance with Meals policy dated 09/08/2015. It did not document in part how staff should treat residents with dignity while providing meal assistance.
2.) R50 has diagnosis not limited to Diabetes Mellitus, Kidney Failure, Spinal Stenosis, Pure Hypercholesterolemia, Hypertensive Heart Disease, Benign Prostatic Hyperplasia, Heart Failure and Bacterial Pneumonia and Acute Hypoxia.
On 12/06/23 at 10:35 AM V6 (CNA) was observed pulling R50 down the hallway backwards in a shower chair. V6 then approached the front of the shower chair and pushed R50 into the shower room backwards in the shower chair.
On 12/06/23 at 10:45 AM V6 (CNA) exited the shower room pulling R50 backwards in the shower chair down the hallway into R50's room.
On 12/06/23 at 11:48 AM V6 entered the nursing station. The surveyor asked V6 at 10:35 AM was she (V6) pulling V50 backwards in the shower chair to the shower room and V6 responded yes. The surveyor then asked V6 at 10:45 AM when she (V6) exited the shower room did, she (V6) pulls R50 backwards down the hallway in the shower chair to R50's room and V6 responded yes to lay him (R50) back in bed and get him dressed. When the surveyor asked V6 the proper way to transport R50 in the shower chair or wheelchair V6 began explaining that R50 is transferred using the mechanical lift. I pull the residents that can't get control of themselves backwards. When I try to push R50 he can't hold himself. I pulled R50 backwards so that he would not fall out of the shower chair.
On 12 07/23 at 08:58 AM R50 stated I can't walk, and it takes two people to get me up out of the bed. I received a shower yesterday. Surveyor asked R50 how the staff transports him to the shower room and R50 responded they do both push me forward and pull me backwards in the shower chair.
On 12/07/23 at 09:20 AM V2 (Director of Nursing) stated When staff are transporting a resident in a wheelchair or shower chair pushing or pulling them, either way is not good. My understanding is the shower chair is not very sturdy. I will in-service V6 (CNA) on another practice for transporting the residents. If the resident is in the shower chair, we should not push the shower chair it is not sturdy and should not be used for long distance transport. To my understanding the shower chair is plastic and it does not matter if you push or pull it, it is not for long distant transfer. When pulling the resident in the shower chair there would be an issue of dignity and a safety issue.
Policy:
Titled Quality of Life - Dignity dated 08/14/09 document in part: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
Titled Policy on Resident Rights dated 11/28/17 document in part: (a) Residents rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside BP (the facility). (1) BP treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to clarify a physician's order for one (R51) resident out of a total sample of 18 residents reviewed for medications.
Findings include:
R51...
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Based on interviews and record reviews, the facility failed to clarify a physician's order for one (R51) resident out of a total sample of 18 residents reviewed for medications.
Findings include:
R51's face sheet documents in part medical diagnosis of Huntington's Chorea.
R51's physician order sheet documents in part an order for Olanzapine 5 MG (Milligram) half a tablet along with 10 MG tablet to equal 12.5 MG by mouth daily for Huntington's Chorea. Order dated 05/17/2023.
After Visit Summary and prescription dated 03/03/2023 documents in part that R51's Olanzapine dose increased from 10 MG to 12.5 MG at that time.
Physician's Progress Notes document in part a note from V30 (R51's Neurologist and Movement Disorder Specialist) dated 09/08/2023 for a follow-up evaluation. It documents in part to increase Olanzapine to 15 MG at night.
Reviewed the corresponding After Visit Summary and prescription from V30 dated 09/08/2023. They document in part Olanzapine 5 MG tablet take one tablet by mouth nightly. Take with the 10 MG pill of Olanzapine for a total of 12.5 MG nightly.
On 12/07/2023 at 10:38 AM, surveyor asked V13 (Nurse) regarding R51's current dosage for Olanzapine. V13 stated Olanzapine 12.5 MG. Surveyor showed V13 the prescription, After Visit Summary, and V30's progress note from 09/08/2023. V13 stated the order was confusing and did not know which dosage R51 was supposed to receive. V13 stated facility will have to call V30 to clarify which dosage R51 is supposed to be on for Olanzapine.
Reviewed R51's progress notes from 09/08/2023 to 09/30/2023. No documentation that facility clarified the order with V30.
Facility's Medication Administration policy last updated July 2017 does not document in part procedures to clarify medication orders that are not well-defined.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their policy to complete a nutritional assessmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their policy to complete a nutritional assessment on residents with a significant change in nutritional status. This failure affected 1 resident (R14) of 6 residents reviewed for nutrition and weight loss.
Findings include:
On 12/05/23 at 12:20 PM, observed V24 (Certified Nursing Assistant/CNA) trying to feed R14 lunch. Observed R14 turning away from food when presented to R14. R14 consumed 100% four-ounces of chocolate oral supplement and eight-ounce container of milk. R14 refused all solid food. R14 appeared very thin.
On 12/06/23 at 09:13 AM, observed R14's breakfast tray. R14 had consumed 100% eight-ounce chocolate oral supplement and 75% container of eight-ounce milk. R14 refused solid food per V24.
R14 was admitted to the facility on [DATE] and has diagnosis which includes but not limited to Unspecified Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Gastro-Esophageal Reflux Disease, Crohn's Disease, Anxiety, Insomnia, Vitamin D Deficiency, Unspecified Kidney Failure, other Symptoms and Signs Involving the Musculoskeletal System.
R14's Physician Orders dated 12/05/23 documents in part (nutritional supplement) 2.0 120 milliliters QID (four times per day) ordered 06/12/23.
R14's MDS (Minimum Data Set) from 11/02/23 BIMS (Brief Interview for Mental Status) was 06 out of 15 indicating severe cognitive impairment and R14 requires substantial/maximal assistance with eating.
R14's care plan completed by V17 (Registered Dietitian) dated 10/31/23 documents in part, R14 is underweight for age, at risk for weight fluctuations due to variable PO intake, meets criteria for moderate protein calorie malnutrition as evidenced by mild losses of subcutaneous fat and muscle mass stores, PO intake <75% of energy needs for >7 days and significant weight loss at 6 months.
R14's most recent Nutritional Progress Note completed by V17 dated 10/31/23 documents in part R14's weight at 86.8 pounds, Body Mass Index (BMI) 14.9, underweight, desirable BMI for age >65 (23-29.9 kg/m2), poor PO intake observed, and resident triggered for significant weight loss at 6 months which is unplanned. No changes to interventions were made at this time.
On 12/06/23, R14's monthly weight data summary as provided by V2 (Director of Nursing) indicates R14's weight as follows: November 2023 81.0 pounds; October 2023 86.6 pounds, August 2023 91.8 pounds, May 2023 90.0 pounds. December 2023 weight was not available.
On 12/07/23 R14's current weight was obtained by V24 (CNA) and V25 (CNA) per surveyor request using mechanical lift scale indicating R14 weighed 81.3 pounds.
On 12/07/23 at 7:17 AM, V17 (Registered Dietitian) stated all V17's documentation is put in progress note section of the resident's electronic health record and there is no paper charting done. V17 stated residents who are high risk are followed more often as needed which include a change in condition such as acquired or worsening pressure wound or significant weight changes over one month (5% or more), three month (7.5% of more), six-month period (10% or more). V17 stated V17 receives and reviews weight data monthly to assess for significant weight changes and informs V2 and then notify the family about any weight loss. V17 stated V17 would review the nutrition interventions in place and adjust the interventions as needed. V17 stated it is important to assess weight changes because it can affect the resident's overall condition. V17 stated for example poor appetite and weight loss could exacerbate preexisting conditions and effect a resident's overall strength needed to maintain current activities of daily living function. V17 stated R14 is severely underweight and meets criteria for malnutrition. V17 stated R14 had a significant weight loss trigger in November for 1 month and 6 months. V17 stated In November V17 has been taking time off for Thanksgiving and a wedding. V17 stated, they told me about it (R14's weight loss). I told them to continue with the interventions in place and I'd assess her when I return. V17 stated potential interventions which could be done are talking to the family about a tube placement, and to give R14 oral supplements with meals in addition to between meals if R14 would accept. V17 stated no one has spoken to the family yet and that V17 will do when V17 returns to work.
On 12/07/23 at 1:01 PM, V1 (Administrator) stated the Registered Dietitian reviews the monthly weights and calculates the weights for weight change triggers. V1 stated the Registered Dietitian then completes an assessment and creates nutrition interventions accordingly.
Facility policy titled, Nutrition Screening and Assessment undated documents in part complete nutritional assessments will be done on any resident with a significant change in nutritional status.
Facility Job Description titled Registered Dietitian undated documents in part responsibilities include assess client's nutritional and health needs, evaluate, and monitor the effect of nutrition plans and practices and make changes as needed and document client's progress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure respiratory care equipment was stored in a manner to prevent possible contamination from viral and/or bacterial pathog...
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Based on observation, interview, and record review, the facility failed to ensure respiratory care equipment was stored in a manner to prevent possible contamination from viral and/or bacterial pathogens for 3 (R47, R68, R75) of 3 residents reviewed who received respiratory care services in a sample of 18.
Findings Include:
1.) R75 has diagnosis not limited to Pneumonia, Dementia with Psychotic Disturbance, Gastrostomy, Cholelithiasis, Gastro-Esophageal Reflux Disease, Dysphagia, Quadriplegia, Seizures, Nutritional Anemias, Age Related Osteoporosis.
R75's Physician Orders document I part: Ipratropium-Albuterol 0.5 MG (Milligram)/3 ML (Milliliter) every 4 hours as needed.
On 12/02/23 at 11:39 AM R75 was observed sitting in a wheelchair at the bedside. R75's nebulizer mask was observed laying on top of a bag on the stand at the bedside with no protective bag.
On 12/05/23 at 12:44 PM Surveyor entered R75's room with V5 (Registered Nurse). V5 approached the stand at the bedside and attempted to push the nebulizer mask inside of the bag in which the nebulizer mask was on top of.
2.) R47 has diagnosis not limited to Asthma, Malaise, Sleep Apnea, Chronic Obstructive Pulmonary Disease, Dementia and Schizophrenia.
R47's Physician Orders document in part: Treatment: CPAP at 10 MHG (Meteorological hydrogen generator) C-Flo at 3, humidity at 3 on HS (Hour of sleep) off early AM. DX: (Diagnosis) Sleep apnea.
R47's Care Plan document in part: Potential for impaired gas exchange. Ineffective airway clearance.
On 12/05/23 at 11:43 AM R47 was observed in bed with the CPAP (Continuous Air Pressure) mask on the stand at the bedside with no protective bag.
On 12/05/23 at 12:47 PM the surveyor entered R47's room with V5 (Registered Nurse). Surveyor asked V5 where R47's CPAP mask was located. V5 responded R47's CPAP mask is not stored in a bag. It is normally stored in a bag when it is removed. Surveyor asked V5 how the CPAP and nebulizer mask are stored when not in use. V5 responded when not in use they are stored in a bag for hygiene purposes and facility protocol.
3.) R68 has diagnosis not limited to Dysphagia, Progressive Bulbar Palsy, Abnormal Involuntary Movements, Depression, Hypertensive Heart Disease and Mid Intermittent Asthma with Status Asthmaticus. R68's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.
R68's Physician Orders document in part: Treatment: Respiratory CPAP on HS (Hour of sleep).
R68's Care Plan document in part: Problem COPD (Chronic Obstructive Pulmonary Disease)/Respiratory. R68 has potential for Impaired gas exchange, Ineffective airway clearance.
On 12/05/25 at 12:41 PM R68 was observed in a wheelchair in her room receiving assistance in preparation for an appointment. R68's CPAP mask was observed laying on the stand at the bedside.
On 12/05/23 at 12:42 PM V5 (Registered Nurse) entered R68's room. When asked about the storage of the respiratory supplies V5 responded that R68 wears the CPAP at nighttime, and it is removed in the morning. R68 CPAP is for the nasals. There was a bag when they remove it. V5 retrieved a plastic bag then stated it should be in a bag for the hygiene. We always clean it and put it in a bag. V5 placed the CPAP in the plastic bag.
On 12/07/23 at 09:20 AM V2 (Director of Nursing) stated The CPAP and Nebulizer mask should be bagged to prevent contamination.
Policy:
Titled Nebulizer Storage dated 12/17/20 document in part: The purpose of this procedure is to appropriately store a handheld nebulizer machine. 1. When equipment is dry, store in a plastic bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to label open insulins for 2 residents (R15, R54) on 1 of 6 medication carts reviewed for medication storage in a sample of 1...
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Based on observations, interviews, and record reviews, the facility failed to label open insulins for 2 residents (R15, R54) on 1 of 6 medication carts reviewed for medication storage in a sample of 18 residents.
Finding include:
On 12/5/23 at 9:51 AM V4 (Registered Nurse) and surveyor conducted inventory of the first-floor medication cart (Long Hall Cart). Observed the following:
R15's opened halfway filled Insulin Lispro Kwik Pen solution 100unit/ml vail was without an open date or a discontinue date.
R54's opened halfway filled Lantus Solostar insulin Glargine Solution Pen-Injector 100unit/ml, give 25 units daily at 9AM was without an open date or a discontinue date.
R54's (2nd) opened Lantus Solostar insulin Glargine Solution Pen-Injector 100unit/ml, give 25 units daily at 9PM was without an open date or a discontinue date.
On 12/5/23 at 9:55 AM V4 (Registered Nurse) stated, Upon opening all insulins, they need to have an open dated and a discontinued date placed on the insulin vail or pen. If a nurse administers an open, undated insulin vial or pen, that can cause high blood glucose levels, because the insulin is less effective.
On 12/5/23 at 11:35 AM V2 (Director of Nursing) stated, All insulins vail, and pens are to be labeled at the time they are open. The label should include the date opened and discontinue date. If the insulins are not labeled, it can potentially cause adverse reactions, and ineffectiveness of the medication that can harm a resident.
Policy:
Storage of Medication dated (4/2007) documents in part:
-Drugs should be correctly labeled and dated
-The facility shall not use discontinued, outdated, or deteriorated drugs
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to follow physician's orders for a specialized diet and update the resident's (R31) comprehensive care plan to correspond to ...
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Based on observations, interviews, and record reviews, the facility failed to follow physician's orders for a specialized diet and update the resident's (R31) comprehensive care plan to correspond to the prescribed diet for one of 18 residents reviewed for nutrition.
Findings include:
R31's Physician Orders document in part an order for Pureed diet.
On 12/05/2023 at 12:09 PM, R31 sat in the dining room for lunch. V21 (Certified Nursing Assistant) asked R31 if (R31) wanted a peanut butter and jelly sandwich. R31 stated yes. V21 brought in R31's lunch tray. V21 unwrapped the peanut butter and jelly sandwich and handed it to R31.
At 12:13 PM, surveyor observed a hand-written meal ticket on R31's lunch tray which documented in part Pureed.
During a telephone interview with V17 (Registered Dietician) on 12/07/2023 at 7:38 AM, V17 stated the physicians generate the residents' diet orders. The diet order in the electronic medical records are the orders that the staff should follow. V17 stated that a resident on a pureed diet should not receive a peanut butter and jelly sandwich. V17 stated the R31's diet was downgraded from mechanical soft to pureed diet to maximize nutritional intake.
Reviewed R31's comprehensive care plan. Focus dated 10/16/2023 documents in part a mechanical diet. Facility did not update it to reflect the physician's order of pureed diet.
Facility's Food and Drink Service policy dated 11/28/2017 documents in part: Each resident receives, and the facility provides food prepared in a form designed to meet individual needs.
Facility's Comprehensive Care Plans policy last updated 07/25/2019 documents in part: [Facility] shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans shall be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 6 residents...
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Based on observation, interview, and record review the facility failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 6 residents (R12, R31, R39, R40, R47, R51) out of 85 receiving foods prepared in the facility's kitchen.
Findings Include:
On 12/06/23 at 11:15 AM, V14 (Dietary Assistant/Cook) stated the pureed consistency should be smooth with no lumps and thick like applesauce. At 11:23 AM, during pureed meal preparation observed V14 add three cups of water and ten pieces of cooked baked fish to the blender before pressing the start button to puree the fish. At 11:26 AM, V14 added an additional one cup water to fish. At 11:27 AM, V14 portioned pureed fish using #8 scoop into individual bowls. There was left over pureed fish in the blender. Surveyor observed the consistency of pureed fish to be thin. Surveyor did not observe V14 reading or looking at a pureed fish recipe before, during or after preparing the pureed fish.
On 12/06/23 at 11:35 AM, V14 stated V14 follows recipes and that V14 reviewed them before V14 started preparing the pureed items so V14 knows how much food to use and how much liquid to add.
On 12/05/23, V1 (Administrator) provided list of residents with diet orders including separate list of two residents who are NPO (Nothing by Mouth).
On 12/06/23 at 3:00 PM, V10 (Food Service Director) provide recipe for pureed fish to surveyor.
On 12/07/23 at 9:55 AM, V1 (Administrator) provided policy titled Standardized Recipes and list of residents receiving a pureed diet to surveyor.
On 12/07/23 at 8:00 AM, V17 (Registered Dietitian) stated via telephone interview that the menus are reviewed by a Registered Dietitian for nutritional adequacy and the pureed recipes should be followed to meet the nutritional calories needed so the residents are getting adequate nutrition per meal. V17 stated using chicken broth instead of water is used to improve the flavor of the pureed food.
Facility recipe titled Pureed Fish lists ingredients for three-ounce portion of fish as 10 portions of fish, 10 Tablespoons of Mashed Potato Flakes and two cups of broth (hot). Recipe instructions documented in part to add small amounts of liquid, blending after each additional until creamy consistency.
Facility policy titled Standardized Recipes undated, documents in part purpose is to provide residents with food that is palatable, prepared in a manner to enhance flavor and appearance, and to prepare food in accordance with the resident's diet order. Procedure documents in part the cook will prepare all food items using the recipes.
Facility job description for position title [NAME] undated, documents in part responsibilities included but not limited to prepare food according to written menu with meals and uses standardized recipes.
Facility job description for position title Dietary Aide undated, documents in part assists in food preparation as assigned.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews, the facility failed to use utensils or wear food handling gloves while handling a resident's (R31) food. The facility also failed to ensure food ...
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Based on observations, interviews, and record reviews, the facility failed to use utensils or wear food handling gloves while handling a resident's (R31) food. The facility also failed to ensure food items were properly stored, failed to ensure staff was performing appropriate hand hygiene in between handling dirty and clean kitchen equipment, and failed to air dry the blender and lid after staff washed it in the three-compartment sink having the potential to affect all 85 residents receiving food prepared in the facility's kitchen.
Findings include:
On 12/05/23 at 9:45 AM, during initial kitchen tour with V10 (Food Service Manager) observed opened bag of potato pancake mix that was not fully closed in dry storage area. The bag had been twisted at the opening but not kept fully closed with a twist tie or clip and it was not wrapped in plastic. Also, observed large 30-pound bag of cornflake crumbs folded over. The top of the bag had been cut all the way across to open the bag, and then folded over but was not fully closed with a twist tie or clip and was not wrapped in plastic.
On 12/05/23 at 9:47 AM, V10 stated opened packaged items should be tied closed or covered tightly in plastic to prevent bugs from crawling inside the item.
On 12/05/23 at 9:58 AM, observed V11 (Dietary Assistant) working in the dish room placing dirty resident plate ware and silverware into a dishwasher rack and then putting the dishwasher rack into the dishwashing machine. At 10:00 AM, observed V11 walk to the clean side of the dishwasher and pull out the cleaned plate ware and silverware in the dishwasher rack from the dish machine. V11 did not perform any hand hygiene in between handling the dirty and cleaned items.
On 12/05/23 at 10:05 AM, V11 stated there is always two staff members working in the dish machine area with the same person always feeding dirty dishes into the dishwasher and then pulling the cleaned rack out of the dishwasher.
On 12/06/23 at 11:19 AM, during pureed food preparation observed V14 (Dietary Assistant/Cook) give blender and lid to the dishwasher to clean in the three-compartment sink. At 11:20 AM, the dishwasher turned over the blender and lid on wire rack. At 11:22 AM, V14 took the blender and lid from wire rack, and placed them on the prep counter. Surveyor observed dripping liquid inside the blender pooling at the bottom and liquid on the blender lid. At 11:23 AM, V14 added three cups of water to the blender and ten pieces of cooked baked fish into the wet blender and blended it. V14 did not wait for the blender and lid to air dry.
On 12/07/23 at 7:48 AM, V17 (Registered Dietitian) stated during phone interview that any opened bags of food bag should be wrapped in plastic wrap or closed with a clip or rubber band to prevent anything from getting inside such as dust, or anything that could spill from another the shelf. V17 stated after kitchen equipment is cleaned it needs to be left out to air dry and that the item should not be used for food preparation until it is fully dry. V17 stated it is important to let the disinfectant chemicals dry out so that they do not get passed to the food. V17 stated once items come out of the dish machine the items are sanitized and clean. V17 stated the same staff should not be placing dirty items into the dish machine and then pulling out the cleaned items from the dish machine unless that staff member is washing their hands in between. V17 stated if the staff members' hands are not washed it could cause cross contamination and has the potential to cause a food borne illness.
On 12/05/23, V1 (Administrator) provided list of residents with diet orders including separate list of two residents who are NPO (Nothing by Mouth).
Facility policy provided by V1 titled, Food Storage dated April 2012 documents in part, food storage areas shall be maintained in a clean, safe, and sanitary manner and food items not requiring refrigeration will not be subjected to sewage, or wastewater backflow or contamination by condensation, leakage, rodents, or vermin.
Facility Job Description provided by V1 titled Food Service Supervisor undated documents in part, responsibilities as assures proper storage and handling of food and supplies.
Facility Job Description provided by V1 titled, Dietary Aide undated document in part, responsibilities as assists in storing food and supplies, adheres to good sanitation and safe procedures and assists in dish and pan washing as assigned.
On 12/05/2023 at 12:09 PM, R31 sat in the dining room for lunch. V21 (Certified Nursing Assistant) asked R31 if (R31) wanted a peanut butter and jelly sandwich. R31 stated yes.
At 12:10 PM, V21 brought in R31's lunch tray. V21 unwrapped the peanut butter and jelly sandwich with bare hands, split it into two pieces, and handed it to R31.
On 12/07/2023 at 1:15 PM, V29 (Certified Nursing Assistant Supervisor) stated that staff should not handle residents' food with bare hands. Staff are supposed to use the utensils to handle the residents' food. V29 stated V21 should have used a knife and fork to split R31's peanut butter and jelly sandwich.
Feb 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that one resident's (R4) urinary catheter drainage bag was covered with a privacy cover. This failure affected one resi...
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Based on observation, interview and record review, the facility failed to ensure that one resident's (R4) urinary catheter drainage bag was covered with a privacy cover. This failure affected one resident (R4) in a sample of 45 residents.
Findings include:
On 1/30/2023 at 10:19am a urinary catheter bag was observed hanging off the bed frame on the left side of R4's bed. R4's bed is the first bed upon entering the room and the urinary catheter drainage bag is visible upon walking past R4's room door when the door is open.
On 1/31/2023 at 9:56am this observation was brought to the attention of V4(Registered Nurse). V4 stated the urinary catheter drainage bag should be covered with a privacy bag. V4 stated the purpose of the privacy bag is because the collection of urine showing in the bag is unsightly. V4 stated the privacy bag is used to provide dignity for the resident.
R4's (1/12/2023) Resident Assessment Instrument documents, in part, Section C. Brief Interview for Mental Status (BIMS) score 15(cognitively intact).
Quality of Life-Dignity Policy dated August 14, 2009 (received via email on 2/1/2023 from V1(Administrator) documents, in part, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure that a call light was within reach for one resident (R40) from a sample of 45.
Findings include:
During patient rounds on 01/30/23 a...
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Based on observation and interviews, the facility failed to ensure that a call light was within reach for one resident (R40) from a sample of 45.
Findings include:
During patient rounds on 01/30/23 at 12:00 pm, R40 was observed in her bed calling for help when surveyor entered her room. R40's call light observed on the floor underneath bed and not within reach.
R40's diagnosis includes but not limited to: Diabetes Mellitus, Dysphagia, Hypertension, Weakness, Anxiety disorder, and Peripheral vascular disease.
R40's Section C of MDS (Minimum Data Sheet) dated 12/24/22 captured a BIMS (Brief Interview of Mental Status) Score of 8, which indicates moderately impaired.
On 01/30/23 at 12:10, V9 (Certified Nurse Assistant) stated in part, The call light should be on her side, next to her so that she can reach it if she needs help . they (residents) should always be able to call in case of an emergency.
02/01/23 at 3:15 pm V1 (Administrator) was asked about expectations with call lights and stated in part, the staff should come timely . the call lights should be within reach of the resident. For people who cannot use call lights, we usually check up on them throughout the day . I'm not sure if we have a call light assessment to assess the resident's ability to use the call light.
On 01/31/23, R40's care plan (updated 12/27/2022) was reviewed and reads in part, Place call light within reach . R40's goal: perform skill appropriately (indicating use of the call light).
Facility document titled Certified Nursing Assistant, emailed to surveyor by V1 on 02/01/23, reads in part, Safety and Sanitation: Keep the nurses' call system within easy reach of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to check placement of the gastrostomy tube before connecting the tube feeding after staff performed ADL (Activities of Daily Living) care for...
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Based on interview, and record review, the facility failed to check placement of the gastrostomy tube before connecting the tube feeding after staff performed ADL (Activities of Daily Living) care for 1 (R26) resident receiving nutrition via a tube feeding in the total sample of 45 residents.
Findings include:
On 01/30/2023 at 12:29pm, the surveyor was standing outside of R26's room and observed V5 (Certified Nurse Assistant/CNA) and V6 (CNA) exiting R26's room.
On 01/30/2023 at 12:30pm, surveyor inquired what V5 and V6 were doing inside R26's room. V5 stated, We just finished changing him (R26). She (V6) just needed to hook the tube feeding. This surveyor asked for the title of V6. V5 stated, She (V6) is the other CNA here.
On 01/30/2023 at 12:34pm, V6 stated, She (V5) did not know how to connect the tube feeding. She (V5) asked me to help her (V5) put the tube feeding for the resident (R26).
On 01/30/2023 at 12:36pm, the surveyor requested V6 to show how V6 connected the feeding tube to R26. V6 stated, This (pointing to the tip of the tube feeding that was attached to the bottle that was on the pump) was on the cap holder (pointing at the back of the pump which was labeled 'Cap Holder'). I (V6) removed it and connect to this (pointing to the tip of the gastrostomy tube connected to the resident). Then I (V6) turned this (pointing to the adapter valve labeled 'off') on this (pointing to the g-tube universal adaptor). This surveyor inquired if g-tube placement was checked before turning the valve towards the g-tube universal adaptor. V6 stated, No.
On 01/30/23 12:45 PM, the surveyor inquired about connecting the g-tube to R26. V4 (Registered Nurse/RN) stated, Ten minutes before doing ADL care and after the care, the CNA is supposed to wait for 10 minutes before putting it back. This surveyor inquired who is supposed to connect it back to the resident. V4 stated, The Nurses. The CNA assigned to him (R26) asked me (V4) to hook it. When I (V4) checked, it was already hooked. I (V4) asked her (V5) who hooked the feeding. She (V5) said She (V5) don't know if she (V6) is a nurse or a CNA. This surveyor inquired if V4 checked for R26 g-tube placement. V4 stated, No. I (V4) just make sure the head of bed is up. Surveyor inquired if CNAs were supposed to hook the g-tube. V4 stated, No. It requires the knowledge or certification to hook the g-tube. Surveyor inquired if CNAs were trained to connect the g-tube. V4 stated, Sometimes we show them if g-tubes are leaking. Surveyor inquired if CNAs were trained in connecting the g-tube. V4 stated, I (V4) don't know about that. Surveyor inquired if V6 was trained to connect the tube feeding. V4 stated, I don't know. This surveyor inquired what could have happened to a resident whose placement of g-tube was not checked prior to connecting the tube feeding. V4 stated, It could lead to aspiration pneumonia, and aspiration pneumonia could lead to death. This surveyor inquired about the standard of practice for connecting a feeding tube. V4 stated, It should be the nurse.
R26's Face sheet documented, in part Other Diagnoses: Dysphagia (difficulty in swallowing), gastrostomy status.
R26's (07/29/2022) Physician Order documented, in part Stop tube feeding 10 minutes before and 10 minutes after each of the following activities: . 2) Changing / turning resident.
R26's (11/18/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-term Memory OK. Coding 1 for Memory problem. C0800. Long-term Memory OK. Coding 1 for Memory problem. Section K. Swallowing/Nutritional Status. K0510. Nutritional Approaches. B. Feeding tube 2. While a Resident.
R26's (11/22/2022) Care Plan documented, in part Problem: is at risk for . aspiration pneumonia related to tube feeding. Check placement and patency of feeding tube before each feeding . Goal: Will not experience aspiration pneumonia.
The 02/02/2023 email correspondence with V1 (Administrator) when this surveyor requested V1 to provide tube feeding policy and procedure in reference to staff responsible for connecting the tube feeding to the resident, document, in part As mentioned our policy doesn't specify the discipline that is required to perform this task.
The 02/02/2023 Administering Nutrition via gastric tube Evaluation performed by V2 (Acting Assistant Director of Nursing/Wound Care Coordinator/Falls Coordinator) for V6 did not include checking for placement of the Gastrostomy tube.
The (October 16, 2017) Administering nutrition via Gastrostomy Tube documented, in part 1. Wash hands and provide privacy. 2. Explain procedure. 3. Help resident to a 30-to-45-degree position. 4. Confirm placement of tube in stomach. a. Aspirate all stomach contents, and measure for residual. b. Reinstall the aspirated gastric contents when less than 100ml through tube into stomach. c. If 100 mL or more than half of last feeding is aspirated, contact physician before proceeding with tube feeding. The feeding is usually held.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure the low air loss mattress setting was based on resident's weight and/or mode for 1 (R52) resident reviewed for pressure...
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Based on observation, interview, and record review the facility failed to ensure the low air loss mattress setting was based on resident's weight and/or mode for 1 (R52) resident reviewed for pressure injury/ulcer prevention in the total sample of 45 residents.
Findings include:
On 01/30/2023 at 10:27AM, R52 was lying on a low air loss mattress; setting was at 150lbs, static mode. This surveyor inquired how much R52 weighs. R52 stated, About 80lbs.
On 01/30/2023 at 10:35 AM, V3 (Minimum Data Set/MDS Coordinator/RN) checked R52's low air loss mattress setting, per this surveyor's request and stated, Low air loss setting is 150lbs, on static. Wound care is the one maintaining this.
On 01/30/2023 at 10:39 AM, V2 (Acting Assistant Director of Nursing/Wound Care Coordinator and Falls Coordinator) checked the setting of R52's Low Air Loss Mattress, per this surveyor's request, and stated, Setting is 150lbs, static. This surveyor inquired if R52's Low Air Loss Mattress Setting was appropriate for R52. V2 stated, No. It should be based on her (R52) weight.
On 01/30/2023 at 10:43 AM, surveyor inquired about the purpose of the Low Air Loss Mattress. V2 stated, It helps with the redistribution of the weight of the resident especially for resident who are prone for skin breakdown. If the setting is too high or too low, the skin is gonna breakdown because the purpose is defeated. This surveyor inquired about the 'static' mode on R52's Low Air Loss Mattress. V2 stated, I (V2) have to check with our nursing consultant.
R52's (12/2022) weight was 80. (lbs/pounds)
R52's (01/2023) weight was 80.4 (lbs)
R52's Face Sheet documented, in part Other diagnoses: age related osteoporosis with current pathological fracture.
R52's (12/05/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R52's mental status as cognitively intact. Section M. Skin Conditions. M0150. Risk of Pressure Ulcers/Injuries. 1. Yes. M1200. Skin and Ulcer /Injury Treatments. B. Pressure reducing device for bed.
R52's (12/07/2022) Care Plan documented, in part Problem: Impaired skin integrity, hx (history) of previous pressure ulcer. Goal: reduce pressure . Pressure relieving devices for bed.
The (April 4, 2019) Support Surface Guidelines documented, in part Purpose. The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for resident at risk of skin breakdown. General Guidelines. 1. Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.
The (undated) (Brand name of bed) Alternating Pressure and Low Air Loss Mattress Replacement system Operator's Manual documented, in part Weight Setting Buttons (+) and (-) The Weight setting buttons . can be used to adjust the pressure of the inflated cells based on the patient's weight.
The (undated) (Brand Name) alternating Pressure Low Air Loss Mattress Replacement System Operator's Manual documented, in part Product Functions. Pressure Adjust Knob. Determine the patient's weight and set the control knob to that weight setting on the control unit. Operating Instructions. Step 6. Determine the patient's weight and set the control knob to that weight setting on the control unit. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition.
The (undated) Drive documented, in part Operation. The STATIC mode and SEAT . mode prevent the patient from bottoming out when the patient is in a seated position.
The (undated) (Brand name of bed) Foam Base Alternating Pressure and Low Air Loss Mattress System USER Manual documented, in part Intended use. The (Brand name of bed) control unit and mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. Pressure adjust Knob adjustable by patient's weight. Turn the Pressure Adjust Knob to set a comfortable pressure level by using the weight scale as a guide. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to ensure that a staff member used personal protective equipment (PPE) and performed hand hygiene before entering and exiting a...
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Based on observation, interviews, and record review, the facility failed to ensure that a staff member used personal protective equipment (PPE) and performed hand hygiene before entering and exiting a contact isolation room. These failures affected one resident (R36) in a sample of 45 residents reviewed for infection control.
Findings include:
On 01/30/23 at 12:40 pm, V9 (Certified Nurse Assistant) was observed entering a contact isolation room of R36 without wearing PPE.
R36's diagnosis including but not limited to: Urinary Tract Infection with ESBL, E. Coli in the urine (Extended Spectrum Beta- Lactamase and Escherichia coli), Hypothyroidism, Hypertension, Vascular dementia, and Fibromyalgia.
R36's Section C- MDS (Minimum Data Sheet) captured a BIMS score (Brief Interview for Mental Status) of 12, which indicates moderately impaired.
On 01/30/23 at 12:40 pm V9 was delivering a meal tray to R36's room when she (V9) entered without donning gown or gloves. V9 was observed arranging V9's meal tray on the bed side table and pulled the table closer to R36.
On 01/30/23 at 12:42 pm, V9 exited R36's room without sanitizing or washing her hands.
On 01/30/23 at 12:43, V9 stated, Yes, I know what the red sign means . it is for isolation .I should be wearing gown and gloves whenever I enter the room. I was only passing a meal tray, so I didn't feel like I needed to wear a gown or gloves I forgot to clean my hands when I left R36's room. I understand that the purpose of using PPE and sanitizing my hands is so that other residents don't get sick from the spread of germs.
R36's Physician Order includes but is not limited to an order for Contact/ Droplet isolation for diagnosis of ESBL E. coli dated 1/05/23
R36's facility care plan dated 1/05/23 reads, R36 is on contact isolation precautions related to ESBL urine . maintain infection control practices.
Facility's policy named: Isolation- Initiating Transmission- based precautions reads, Transmission- Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinues them, which should occur after pertinent criteria for discontinuation are met
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have an operational call light for one resident (R55)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have an operational call light for one resident (R55) reviewed for accommodation of needs in the sample of 45.
Findings include:
During resident rounds on 01/30/23 at 10:35 am, R55 was observed in bed, calling out for help with the call light string in his hand; attempting to activate the call light.
R55 is a [AGE] year old male with diagnosis including but not limited to: Diabetes, Hypertension, Major Depressive disorder, Atrial Fibrillation, and Parkinson's disease.
R55's Section C - MDS (Minimal Data Sheet) dated 12/17/22, captured a BIMS Score (Brief Interview for Mental Status) of 13 (indicating cognitively intact)
R55 pulled on the call light string, but the call light and the alarm at the nurse's station did not activate it. At 10:40 am, surveyor asked V10 (Certified Nurse Assistant) to come to R55's room for assistance.
At 10:40 am, R55 tried again to activate the call system but was unsuccessful.
V10 activated the call light to the adjacent bed (in the same room), and the call alarm and call light outside of room was activated.
V10 then pulled R55's call device, but could not activate the call light.
On 01/30/23 at 10:43 am, V10 stated in part, the other call light is definitely easier to use (referring to the call light near the empty bed in R55's room). I think his call light is stuck. He may have to pull harder and pull downward.
V10 tried to activate R55's call device a second time, but was not successful.
V10 stated, I think there is a problem with the call light, I will let the nurse know so that she can notify maintenance.
At 10:45 am, V8 came into the R55's room and stated, I will inform maintenance of the call light not functioning correctly'.
On 02/01/23 at 3:15 pm, V1 (administrator) stated, the staff should come timely when a resident calls for help . the call lights should be within reach and working. For people who cannot use call lights, we usually check up on them throughout the day . I'm not sure if we have a call light assessment to assess the resident's ability to use the call light. The metal piece on the bottom of the call light makes it easier for the patient to use it . sometimes, if the string is not threaded thought the metal piece, it will be difficult to activate the call light. I will have maintenance look at the call light.
R55's facility care plan dated 12/20/2022 reads, Use of call light goal: perform skill appropriately.
Facility policy dated 12/5/2019 reads, The purpose of both audible and visual aids is to provide redundancy in case one of the aids fail. The system will be maintained as needed by the maintenance staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record review, the facility failed to ensure that oxygen tubing and humidifier bottle were changed and dated for 5 residents: R13, R46, R48, R52 and R74. These fa...
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Based on observation, interviews, and record review, the facility failed to ensure that oxygen tubing and humidifier bottle were changed and dated for 5 residents: R13, R46, R48, R52 and R74. These failures affected five residents (R13, R46, R48, R52, R74) in a sample of 45 residents reviewed for respiratory care.
Findings include:
1. On 01/30/23 at 9:40 am, R74 was sitting near the nurse's station. R74 had a nasal cannula (oxygen tubing) in his nostrils, delivering supplementary oxygen, which was not labeled with a date on it.
R74's diagnosis includes but not limited to: Anemia, Malignant neoplasm of prostate, Diabetes mellitus, Osteoarthritis, Atherosclerotic heart disease, and cardiac pacemaker.
R74's section C of MDS (Minimum Data Sheet) dated BIMS (Brief Interview for Mental Status score of 10, which indicates moderately impaired.
On 01/30/23 at 9:40 am, V8 (Registered Nurse/RN) stated that the night shift nurses usually are the ones to change and date oxygen tubing The tubing is changed to make sure that no bacteria is in it It's usually changed weekly.
01/30/23 at 10:20 am, V4 (RN) said, for infection control, we practice handwashing, for changing O2 tubing we wear our PPE (Personal Protective Equipment) etc.
R74's Physicians orders includes, but not limited to an order for Oxygen at 2 L (Liters) continuous.
R74's care plan dated 12/09/2022 reads in part, R74 is at risk of lower respiratory tract infection and other complications . Nurses are to maintain infection control practices .R74 is on oxygen therapy.
5. On 01/30/2023 at 11:20am observed R46's oxygen tubing with no label of date indicating when the tubing was changed.
On 01/31/2023 at 9:56am V4(RN) stated the oxygen tubing is to be changed weekly and it is usually done by the night shift. V4 stated there is a logbook the nurses use to log every time the tubing is changed. V4 stated the nurses are to also label the tubing and canister with the date the tubing was changed. V4 stated the purpose of changing the oxygen tubing and dating the oxygen tubing is to prevent infection.
R46's (12/08/2022) Resident Assessment Instrument documents, in part, Section C. C0100. Should Brief Interview for Mental Status be Conducted? 0. No (resident is rarely/never understood).
The (November 4, 2017) Oxygen Concentrator documented, in part Care of concentrator: b. Replace humidifier every 2 weeks. c. Replace nasal cannula or mask every 2 weeks.
The (January 16, 2017) Oxygen Concentrator use documented, in part The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . among residents and staff. Infection Control Considerations Related to Oxygen Administration. 4. c. Change the humidifier every fourteen (14) days. 5. Change the oxygen cannula and tubing every fourteen (14) days.
2. On 01/30/2023 at 10:03am, R48's nasal cannula was attached to an oxygen concentrator. The cannula and humidifier bottle were not dated.
On 01/30/2023 at 10:18am, V3 (MDS Coordinator/RN) checked R48's nasal cannula and humidifier bottle, per this surveyor's request, and stated, Oxygen tubing and bottle were not dated. Surveyor inquired if nasal cannula and humidifier should be dated. V3 stated, Yeah, of course, so we (facility) will know when these should be changed to prevent infection.
R48's Face Sheet documented, in part Other diagnoses: pneumonia.
R48's (12/07/2022) Physician order documented, in part Oxygen orders. Oxygen at 2.5L/MIN via nasal cannula continuously.
R48's (12/1/2022) Minimum Data Set (MDS) documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-term Memory OK. Coding 1 for Memory problem. C0800. Long-term Memory OK. Coding 1 for Memory problem.
R48's (12/15/2022) Care Plan documented, in part Problem at risk for lower respiratory tract infection: Goal: will be free of any signs and symptoms of lower respiratory tract infection . Is on O2 therapy.
3. On 01/30/2023 at 10:27 AM, R52's nasal cannula was attached to an oxygen concentrator. The nasal cannula was not dated, and the humidifier bottle was dated 1 / 4 (January 4th).
On 01/30/2023 at 10:35 AM, V3 checked R52's nasal cannula and oxygen concentrator's humidifier bottle, per this surveyor's request and stated, Omg , they did not change these too. The humidifier bottle is dated 1 / 4 (January 4th) and the nasal cannula is not dated.
R52's Face Sheet documented, in part Other diagnoses: Chronic Obstructive pulmonary disease
R52's (12/02/2022) Physician Order documented, in part Oxygen Therapy flow rate 3L-4L/min via nasal cannula continuously.
R52's (12/05/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R52's mental status as cognitively intact. Section O. Special Treatments, Procedure, and Programs. Respiratory Treatments C. Oxygen Therapy While not a resident and While a resident.
R52's (12/05/2022) Care Plan documented, in part Problem: potential for ineffective airway clearance. Administer O2 (oxygen) as ordered. Goal: breath sounds within normal limits.
4. On 01/30/2023 at 10:58 AM, R13's nasal cannula was attached to an oxygen concentrator. The date on the oxygen concentrator's humidifier bottle was 1 / 4 (January 4th) and the nasal cannula was not dated.
On 01/30/2023 at 11:00am, V3 checked R13's nasal cannula and the oxygen concentrator's humidifier bottle, per this surveyor's request and stated, The nasal cannula is not dated, and the humidifier bottle is dated 1 / 4.
R13's Face Sheet documented, in part Admitting Diagnosis: Pneumonia.
R13's (12/15/2021) Physician Order documented, in part O2 (oxygen) at 2 Liters per minute via nasal cannula as needed for shortness of breath.
R13's (12/01/2022) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 04. Indicating R13's mental status as severely impaired. Section O. Special Treatment . Respiratory Treatments C. Oxygen Therapy while a resident.
R13's (12/07/2022) Care Plan documented, in part Problem (COPD/Respiratory): Potential for ineffective airway clearance . Goal: breath sounds within normal limits. Administer O2 as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents' controlled medications. This failure has the potentia...
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Based on interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents' controlled medications. This failure has the potential to affect all 64 residents on the second and third floors of the facility.
Findings include:
On 1/30/23 during the facility's entrance conference, the facility census shows that there are 31 residents on the second floor and 33 residents on the third floor, a total of 64 residents on both floors.
On 1/30/23 at 12:50pm on the second floor with V4 (Registered Nurse/RN), the Controlled Substances Check Form for controlled substances on the second floor shows several missing entries of nurses' signatures, interpreted to mean that there were some shifts that no nurse was accountable or responsible for the narcotics on the floor. The missing entries for January 2023 include: 1/1/23, 1/8/23, 1/9/23, 1/10/23, 1/16/23, 1/25/23, 1/27/23, 1/28/23, and 1/29/23. V4 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V4 responded that she does not know whose signatures were missing, and that she always signs the book.
On 1/30/23 at 12:35pm on the second floor with V13 (RN), the controlled substances check form for the third floor showed the following missing entries: 1/5/23, 1/6/23, 1/7/23, 1/14/23, 1/15/23, and 1/19/23. V13 was asked why some nurses did not sign the signature form; V13 stated that every nurse should sign the sheet at the beginning and at the end of the shift.
On 2/1/23 at 10:20am, V2(Acting Assistant Director of Nursing/Wound Care Nurse) stated that nurses must count the controlled medications and sign at the beginning and at the end of their shifts.
Facility's policy titled Controlled Substances dated 12/5/2012 says in #7: Nursing Staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together.
The facility did not follow this policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents' expired eye drops were discard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents' expired eye drops were discarded; and failed to label opened multidose eye drops with the open dates. This failure has the potential to affect 5 residents (R13, R28, R39, R49, and R54), reviewed for medication storage, in a total sample of 45 residents.
Findings include:
On [DATE] at 12:35pm during observation of medication carts on the third floor with V13 (Registered Nurse/RN), R39's Dorzolamide-Timolol Ophthalmic Eye drops (10 ml-milliliters) was observed to be opened without open date. V13 stated I know it should be dated. I will discard it and order a new one.
On [DATE] at 12:50pm during observation of medication carts on the second floor with V4(RN), the following were noted:
R49's Latanoprost 0.005 percent (%) Eye Drops was observed to have an open date [DATE] and an expiration date of [DATE]. V4 stated that it is expired and should have been discarded, and that all eye drops should have an open date so they would know when to discard them.
R28's Brimonidine-Timolol 0.2 %-0.5 % was observed to be opened with no open date.
R28's Artificial Tears was observed with open date of [DATE].
R54's Artificial Tears was opened with no open date.
R13's Latanoprost 0.005 % Eye drops was opened with no open date.
On [DATE] at 10:20am, V2(Acting Assistant Director of Nursing/Wound Care Nurse) stated that all eye drops are supposed to be labeled with the open date because that will determine the expiration date to discard them.
Facility's policy titled Medications with Special Expiration Dates dated 12/2012 states that Eye Drops get expired 90 days after opening.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure expired food was discarded on or before the expiration date in the walk-in cooler. This failure has the potential to a...
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Based on observation, interview, and record review, the facility failed to ensure expired food was discarded on or before the expiration date in the walk-in cooler. This failure has the potential to affect 86 residents in the facility who are receiving an oral diet.
The findings include:
On 01/30/23 at 9:24am V14(Food Service Director) and surveyor observed a five-pound white plastic container of 2% low fat cottage cheese with a noted expiration date of January 26, 2023, on a shelf in the walk-in cooler.
On 02/01/23 at 10:55 AM V14 stated the purpose of removing expired foods from the walk-in cooler and freezer is because the residents can get sick from expired foods.
The facility's Expired Food Policy dated April 12,2022 documents, in part, 1. Dietary staff engaged in food preparation will routinely check products before use for their printed expiration date. 2. Any food stuffs which have reached their printed expiration date shall not be served to residents. 3. Any such product may be returned to the vendor, donated to a food depository, or disposed of accordingly.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
- • 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Buckingham Pavilion's CMS Rating?
CMS assigns BUCKINGHAM PAVILION an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Buckingham Pavilion Staffed?
CMS rates BUCKINGHAM PAVILION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 57%, which is 10 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Buckingham Pavilion?
State health inspectors documented 29 deficiencies at BUCKINGHAM PAVILION during 2023 to 2024. These included: 28 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Buckingham Pavilion?
BUCKINGHAM PAVILION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 235 certified beds and approximately 105 residents (about 45% occupancy), it is a large facility located in CHICAGO, Illinois.
How Does Buckingham Pavilion Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, BUCKINGHAM PAVILION's overall rating (4 stars) is above the state average of 2.5, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Buckingham Pavilion?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Buckingham Pavilion Safe?
Based on CMS inspection data, BUCKINGHAM PAVILION has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Buckingham Pavilion Stick Around?
Staff turnover at BUCKINGHAM PAVILION is high. At 57%, the facility is 10 percentage points above the Illinois average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Buckingham Pavilion Ever Fined?
BUCKINGHAM PAVILION has been fined $9,750 across 1 penalty action. This is below the Illinois average of $33,176. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Buckingham Pavilion on Any Federal Watch List?
BUCKINGHAM PAVILION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.