Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
145285
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, 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.
Residents Affected - Few
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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
R68 has potential for Impaired gas exchange, Ineffective airway clearance.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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.
Residents Affected - Many
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.
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145285
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/08/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Buckingham Pavilion
2625 West Touhy Avenue
Chicago, IL 60645
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
the blender and lid to air dry.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Many
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145285
If continuation sheet
Page 12 of 12
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the December 8, 2023 survey of BUCKINGHAM PAVILION?
This was a inspection survey of BUCKINGHAM PAVILION on December 8, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BUCKINGHAM PAVILION on December 8, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.