Inspection visit

InspectionNovember 15, 2024

BUCKINGHAM PAVILIONCMS #1452859 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 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. **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 (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 14 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 11/15/2024 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 with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 2 of 14 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 11/15/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 3 of 14 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 11/15/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 4 of 14 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 11/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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). 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 5 of 14 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 11/15/2024 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 0644 Findings include: Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Some 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 6 of 14 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 11/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 7 of 14 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 11/15/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 8 of 14 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 11/15/2024 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 0677 toileting hygiene, R45 is completely dependent where the helper does all the effort. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 9 of 14 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 11/15/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 10 of 14 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 11/15/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 11 of 14 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 11/15/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 12 of 14 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 11/15/2024 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Many Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 13 of 14 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 11/15/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145285 If continuation sheet Page 14 of 14

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Citations

9 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.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0644GeneralS&S Epotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0790GeneralS&S Dpotential for harm
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
0842GeneralS&S Cno actual harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.

FAQ · About this visit

Common questions about this visit

What happened during the November 15, 2024 survey of BUCKINGHAM PAVILION?

This was a inspection survey of BUCKINGHAM PAVILION on November 15, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BUCKINGHAM PAVILION on November 15, 2024?

Yes, 9 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.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·November 15, 2024