Inspection visit
Inspection
23 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 23 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to follow their policy to develop and implement a
comprehensive person-centered care plan for one (R55) of five residents reviewed in a sample of 18.
Findings include:
R55 is a [AGE] year-old individual admitted to the facility on [DATE]. R55's medical diagnosis includes but
not limited to: Cerebral Infarction due to embolism of left middle cerebral artery. R55's physician order sheet
(POS) documents R55's orders to include but not limited to: Eliquis Oral Tablet 5 MG (Apixaban) Give 1
tablet via G-Tube two times a day for CVA (Cerebral Vascular Accident). Active (Start date for
medication)7/1/2023.
On 8/9/2023 at 2:54 pm, V16 (Minimum Data Set Coordinator -MDS) and surveyor reviewed R55's care
plan. V16 said R55's anticoagulant medication, Eliquis Oral Tablet 5 MG, was not care planned and it
should have been care planned after it was ordered so that R55's nurses can monitor for side effects
including bleeding, bruising, blood clots, and effectiveness of the medication. V16 further stated that a
resident's specialized care plan paints a picture of the resident specific needs, and it is customized to meet
the individual needs of that resident. V16 said she does the care plans for medications including but not
limited to psychotropic and anti-coagulant medications for all residents. V16 further said for new
admissions, she reviews the charts from the hospital records when the resident gets to the facility, then
then she adds the diagnosis in the residents' electronic medical chart, and once the nurses put the orders
in the residents' electronic record, V16 checks the orders and based on the orders, she develops the
residents individualized the care plan. V16 said after doing daily morning rounds with the inter- disciplinary
team, if there are any changes or resident's orders, she updates the care plan. V16 said if R55's medication
Eliquis 5MG is not care planned, R55 can develop adverse side effects from the medications, and it might
not be monitored because the medication is not care planned and nurse will not see interventions or goals
for the medication.
On 8/9/2023 at 12:55pm, V2 (Director of Nursing-DON) said all psychotropic, blood pressure, diuretics, and
anticoagulant medications are care planned to check for effectiveness of the medications, side effects and
care plans guide the nurses and gives parameters for what interventions, goals, and side effects of the
medications that the nurses need to watch for. V2 further said that the care plan guides, and based on the
care plan goals and interventions the nurses will know when to contact the nurses physician for any
adverse side effects of the medication(s).
Policy titled Comprehensive Care Plans, no date, documents;
(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 15
Event ID:
145767
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
-A comprehensive care plan than includes measurable objectives and timetables to meet the resident's
medical, nursing, mental and psychological needs shall be developed for each resident.
Level of Harm - Minimal harm
or potential for actual harm
-The comprehensive care plan has been designed to:
Residents Affected - Few
Incorporate identified risk factors associated wit identified problems,
Reflect treatment goals and objectives in measurable outcomes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 2 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure a medication error rate of
less than 5% for two (R13, R179) out of five residents reviewed for medication administration resulting in a
12.12% error rate.
Residents Affected - Few
Findings Include:
R179's Facesheet documents that R179 has diagnoses not limited to major depressive disorder,
Parkinson's disease, chronic systolic heart failure, and paroxysmal atrial fibrillation.
R179's medication administration record (MAR) dated 08/01/2023 - 08/09/2023 documents:
Co Q 10 (Ubidecarenone) 30mg- 1 tab by mouth one time a day.
Sertraline 100mg- 1 tablet by mouth one time a day.
Review of R179's MAR documents that V9 signed the MAR to indicate that the above medications were
given. This documentation does not align with direct observation.
On 08/09/2023 at 8:55AM, observed that these medications were not given during medication
administration pass with V9 (Licensed Practical Nurse/LPN).
R13's Facesheet documents that R13 has diagnoses not limited to: Chronic Kidney Disease, Chronic
Obstructive Pulmonary Disease, Chronic Heart failure, atrial fibrillation, and major depressive disorder.
R13's medication administration record (MAR) dated 08/01/2023 - 08/09/2023 documents:
Potassium Chloride 10 MEQ- 1 tablet by mouth in the morning.
Vitamin D3 75mcg- 1 tablet by mouth one time a day.
Review of R13's MAR documents that V9 signed the MAR to indicate that the above medications were
given. This documentation does not align with direct observation.
On 08/09/2023 at 8:59AM, observed that these medications were not given during medication
administration pass with V9 (Licensed Practical Nurse/LPN).
On 08/09/2023 at 2:01PM, V9 (Licensed Practical Nurse/LPN) located in conference room and states, I
can't believe that I did not give those medications. I thought I gave them all, I don't know what happened. I
don't have a reason or explanation of why I did not administer the medications to R179 and R13.
On 08/09/2023 at 2:22PM, V9 (LPN) re-enters the conference room and states, I forgot to give those
medications to R13 and R179, so now I have to call the doctor. V9 was not consulted or advised on any
actions to be taken.
Facility Policy dated 08/15/2022, titled Medication Administration Policy documents in part,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 3 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0759
Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the
right resident, right medication, right dosage, right route, and right time.
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:
145767
If continuation sheet
Page 4 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure liquid medications were properly
labeled with an open date and ensure that one out of two medication carts reviewed were locked/secured
while unattended. These failures have the potential to affect 27 residents residing in the facility.
Findings Included:
On 08/08/2023 at 9:39AM, an observation of the medication cart (Identified as 1 East Medication Cart) on
the first floor of the facility with V4 (Registered Nurse/RN) present revealed the following medication to be
opened and undated: Levetiracetam 100mg/ml with R66's name on it. V4 stated that she administered R66
the above medication this morning and that there should be an open date labeled on the medication.
On 08/08/2023 at 9:53AM, an observation of the medication cart (Identified as 2 East Medication Cart) on
the second floor of the facility with V5 (Licensed Practical Nurse/LPN) present revealed the following
medication to be opened and undated: Albuterol Sulfate 2.5mg/3ml with R69's name on it. Ipratropium
Bromide 2.5mg/3ml with R21's name on it. V5 stated that all liquid medications should be labeled with an
open date when they are first opened.
On 08/09/2023, during a medication administration pass with V9 (Licensed Practical Nurse/LPN) from
approximately 8:00AM to 9:00AM, V9 observed leaving medication cart (identified as 2 [NAME] team 2
medication cart) unlocked and unattended. V9 stated that medication carts should not be left unlocked
when unattended because someone could potentially access medications inside of the cart.
On 08/09/2023 at approximately 8:00AM, V9 (LPN) stated that she was responsible for administering
medications to residents residing in room [ROOM NUMBER] and rooms 244-254. V9 is assigned to the 2
[NAME] team 2 medication cart, which stores the medications for the room numbers listed above. Facility
Census dated 08/08/2023 documents that a total of 24 residents reside in the room numbers listed above.
On 08/10/2023 at 10:50AM, V2 (Director of Nursing/DON) stated that all medications, including stock
supply should be labeled with an open date.
Facility Policy dated 08/15/2022, titled Medication Administration Policy documents in part, Multi-use vials
and house stock liquids must be dated when opened. Liquids must be dated when opened.
Facility Policy dated 12/10/2022, titled Medication Storage in the Facility documents in part, 3. Medication
rooms, carts, and medication supplies are locked and attended by person with authorized access.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 5 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
Based on observation, interview, and record review, the facility failed to follow policy taking in to account
preferences of food and beverages for 3 of 3 residents (R53, R52, and R11) during dining observations.
Residents Affected - Few
These failures have the potential to affect 3 residents (R53, R52, and R11) meal preference and
consumption of food and beverage during meals.
Findings include:
On 08/08/2023 at 12:21 PM, at the dining room during lunch, R53 and R52 who were seated on the same
table were asked if they are enjoying their food. R53 said, Look what they gave me (holding grilled cheese
sandwich), they did not give me my chocolate milk. They always fail to give me my chocolate milk. Then
R52 said, Look what they gave me (holding a grilled cheese sandwich). I would like a Tuna Sandwich, but I
always don't get what I asked. V17 (Dietary Staff) was informed but responded, I am not sure what they are
getting. V18 (Director of Dietary and Dining Services) were informed and said, Let me talk to them. During
conversation with R53 and R52, R53 said, I did not receive my chocolate milk. Then R52, when asked if
she would like tuna sandwich said, Yes, I would like tuna sandwich. R53's tray ticket under preference reads
chocolate milk. And R52's tray ticket under preference has only tuna sandwich. V18 said, Dietary staff much
always check meal tickets and follow food preference. I will make sure staff provide what the resident has
on their meal ticket as their preference.
On 08/10/2023 at 12:17 PM, at the same dining room, R11 was asked how her lunch was. R11 said, I like
chocolate milk, but they gave me this (holding a carton of 2% milk). They say chocolate milk is not available.
On 08/10/2023 at 12:45 PM, V18 was informed and said, I am very upset, I specifically told them to follow
meal tickets. I will check who gave R11 milk instead of chocolate milk. V18 came back with V19 (Certified
Nursing Assistant/CNA) and said, I will let V19 explain to you because she gave R11 the chocolate milk. At
first V19 said, I asked R11 what she wanted, and she said regular milk. Later, V19 said, I placed chocolate
milk on R11's table, and somebody took it. V18 then said, It is the facility staff, may it be nursing or dietary
staff to make sure residents get food and beverages that they prefer. I understand that it is not good when
you order a specific food, and you get a different one.
Food Preferences policy dated 2023, reads:
The healthcare community provides each resident with a nourishing, palatable, well-balanced diet that
meets their nutritional needs and takes their food and beverage preferences in to account.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 6 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility did not ensure proper sanitation and food
handling practices to prevent the outbreak of foodborne illness. This failure has the potential to affect the 87
residents that are served food from the kitchen.
Findings include:
On 8/8/23 at 9:40 AM, surveyor toured the facility kitchen with V18 (Director of Dietary and Dining) and
observed:
-a staff lunch bag and a pan of roast beef (to be served at lunch) on the food prep counter/cooking area.
-a bag of dry cereal not completely sealed.
-7 bottles of thickened orange juice, nectar consistency with use by date 5/24/23.
-a bag of dry pasta with no OPENED date.
-a package of hotdog buns not sealed closed.
On 8/8/23 at 10:40 AM, V21 (Cook) stated staff personal belongings are not supposed to be in the kitchen
on cooking areas according to the rules. It is not sanitary. There is a potential for contamination and for
residents to get bacteria.
On 8/10/23 at 11:45 AM, V18 (Director of Dietary and Dining) stated because a staff person placed their
lunch bag on the food prep counter/cooking area there was a potential to contaminate food because the
bag was from outside. The bag should not have been there. Should not have staff personal items in the
kitchen. If contamination occurs, there is potential for the residents to get sick. The thickener should have
been discarded on the day it expired at the end of the night. Everybody is responsible for checking
expiration dates before they use the product. The thickener should have been thrown out to prevent
residents from getting sick. Packages that are not properly sealed or resealed can become contaminated
and can attract rodents. Items should be labeled with the Opened date, so it is known when to throw it
away. It lasts for only a certain amount of time after it is opened. When you open something, it should be
dated with the date it was opened. Everything should be labeled with the date it was opened so you know
when to throw it away.
Facility policy Food Safety Requirements-Use and Storage of Food and Beverage Brought in for Residents,
Food Procurement, not dated, documents in part: It is the policy of this facility to provide safe and sanitary
storage, handling, and consumption of all foods. Cross-contamination means the transfer of harmful
substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth
towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods. The
objective/intent of this requirement is to ensure that the facility follows proper sanitation and food handling
practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne
illnesses begins when food is received from the vendor and continues throughout the facility's food handling
processes.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 7 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility policy Labeling and Dating Foods, date 2010, documents in part: Prepared and packaged foods will
be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for
the residents and minimize waste. Potentially hazardous foods that contain a Sell by date, will be labeled
with the date it is opened and a use by date which is either the 6th day it is opened or the Sell by date,
whichever is sooner. Commercially processed foods that have been prepared and packaged by a food
processing plant will be labeled with the date it is opened. This will be discarded either on the 6th day or the
Best Used By date.
Event ID:
Facility ID:
145767
If continuation sheet
Page 8 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and review of records, the facility failed to date and refrigerate food from
outside source to 1 out of 1 resident (R41) reviewed for food on the bedside.
Residents Affected - Few
These failures have the potential to affect 1 resident (R41) in consuming food that are not appropriate for
consumption.
Findings include:
On 08/08/2023 at 11:45 AM, R41 was seen alert and verbally able to express his thoughts. R1 has a lot of
food on the bedside table and drawer, including a sandwich dated 8/6/2023, milk in a carton, cucumber,
peanuts on the bottle, crackers, Tortillas, Dreamies Raspberry, Donette's Danish, chips on a zip lock all not
dated, and a banana with discoloration. R41 said, Some of this food is old, but I don't to know when I got
them.
On 08/10/2023 at 12:15 PM, V18 (Director of Dietary Services and Dining Services) said, Food on the bed
side must be dated to know if it is still good to be consumed. Then it must be placed in resident's personal
refrigerator that must be checked daily for temperature. If the resident does not have personal refrigerator, it
will be placed inside the refrigerator for food at the Nurses' Station. All food must be dated to determine
when to discard.
On 08/10/2023 at 12:23 PM, R41 still has a bottle of peanut that was not dated.
Per facility policy of Food Brought in by Family or Visitors Personal Refrigerator dated 2021, it reads:
Clients may accept food from family or visitors. The healthcare community provides visitor information on
safe food handling practices. Food or beverages brought in by family or visitors may be stored in the client's
personal refrigerator or in a food refrigerator on the unit. Perishable foods are discarded on the sixth day
after preparation / opening or on the expiration date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 9 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to properly contain waste in the
dumpsters. This failure has the potential to affect all 73 residents in the facility.
Residents Affected - Many
Findings include:
On 8/9/23 at 9:00 AM, toured the dumpster area with V18 (Director of Dietary and Dining). Observed three
dumpsters, two recycle dumpsters with cardboard and plastic in them and one trash dumpster with bags of
trash in it. The lids on all three dumpsters were open.
On 8/9/23 at 9:20 AM, V22 (Maintenance) stated the dumpster lids should be closed.
On 8/9/23 at 9:25 AM, V23 (Maintenance Director) stated the lids should be closed on the dumpsters. They
should be closed because of the risk to attract rodents, and pests.
On 8/10/23 at 11:45 AM, V18 (Director of Dietary and Dining) stated the dumpsters should be closed. There
is a potential for odors and to attract cockroaches, flies, rodents. There is potential for pest infestations in
the building.
Facility Pest Control Physical Environment policy, date 4/1/2020, documents in part: Purpose: To ensure the
facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of
residents, facility staff, and visitors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 10 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility has the following failures related to infection
prevention and control. The facility failed to clean and disinfect reusable equipment (blood pressure cuff
device) used by four residents (R13, R51, R62, and R179). The facility also failed to follow appropriate
infection control procedures after using a glucometer on one (R14) of one resident observed for a blood
glucose reading in a total sample of 5 residents reviewed during medication administration. Facility also
failed to provide access to perform hand hygiene for 1 out of 20 residents (R41) with multiple infections
reviewed for facility infection control and prevention practices.
Residents Affected - Some
Findings include:
On 08/08/2023 at 11:55 AM, R41 was seen alert and verbally able to express his thoughts. R41 has 2
urinals hanging on the right-side rails of his bed. R41 said, I still have discomfort during urination, and
frequently urinating during night. I cannot go to toilet by myself, and I also need to wash my hands in the
toilet. I need to use the walker (pointing at the right side of the bed where walker was located). R41 was
asked how he performs hand hygiene after using his urinals. R41 did not respond. Upon review of R41's
room, no hand sanitizer available for him to use.
R41 has multiple antibiotics for UTI (Urinary Tract Infection) including ESBL (Extended-spectrum
Beta-Lactamases) in urine. Enterobacterales can produce enzymes called extended-spectrum
beta-lactamases (ESBLs). ESBL enzymes break down and destroy some commonly used antibiotics,
including penicillins and cephalosporins, and make these drugs ineffective for treating infections. CDC
information on ESBL dated 11/22/2019.
Hand Hygiene policy reads:
To ensure that all individuals use appropriate hand hygiene while at the facility. The facility considers hand
hygiene the primary means to prevent the spread of infection. Alcohol-based hand hygiene products can
and should be used to decontaminate hands.
R41's care plan on Enhanced Barrier Precautions reads: R41 is at risk of acquiring MDRO (Multi-Drug
Resistant Organism). Per DPH Multi-Drug Resistant Organism Toolkit for LTC (Long Term Care) dated
08/2019, it reads:
When a drug that can normally be used to treat an infection does not work to treat the organism causing
the infection, the organism is called resistant to that drug. Multidrug-resistant organisms (MDROs) are
organisms or microbes that have become resistant to multiple types of drugs that are normally used to treat
them. MDROs can include fungi, viruses, and parasites, but many are bacteria. Antimicrobial resistance is
the ability of these microbes to resist the effects of drugs - that is, the germs are not killed, and their growth
is not stopped. One type of antimicrobial resistance is antibiotic resistance, when bacteria are resistant to
the antibiotics used to treat them
R41's antibiotic are as follows:
Levaquin 250 MG to give 1 tablet by mouth in the afternoon for ESBL (Extended-spectrum
Beta-Lactamases) of urine for 1 week until 04/06/2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 11 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Nitrofurantoin Macrocrystal Oral Capsule 100 MG Give 1 capsule by mouth two times a day for ESBL of
urine until 04/06/2023.
Ceftriaxone Sodium Injection Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for
antibiotic for 4 Weeks order date 5/2/2023 to 5/30/2023.
Residents Affected - Some
Ampicillin-Sulbactam Sodium Intravenous Solution Reconstituted 1.5 (1-0.5) GM Use 1.5 gram
intravenously every 6 hours for UTI (Urinary Tract Infection) for 4 Weeks order date 6/9/2023 until 7/3/2023.
Voriconazole Oral Tablet 50 MG Give 2 tablet by mouth every 12 hours for fungal infection order date
7/14/2023.
On 08/09/2023 at 09:40 AM, V2 (Infection Preventionist / Director of Nursing) said, Yes, we provide hand
sanitizers or alcohol-based hand rub. Since, R41 uses urinal at the bedside, he needs to perform hand
hygiene. R41 needs hand sanitizer on the bedside.
On 08/09/2023 at 8:19AM, V9 (Licensed Practical Nurse/LPN) performed a blood glucose reading on R14
using a glucometer.
On 08/09/2023 at 8:19AM, V9 observed wiping the same glucometer used on R14 with a Bleach Wipe for
approximately 3 seconds and then disposing the Bleach Wipe in a garbage container. V9 then placed the
glucometer back into the top drawer of the medication cart.
On 08/09/2023 at 08:25 AM, V9 (License Practical Nurse/LPN) entered R62's room with the blood pressure
device and placed the blood pressure cuff on R62's arm to obtain the blood pressure reading of 147/80. V9
(LPN) returned to the medication cart with the blood pressure machine to prepare R62's medications. V9
did not clean the blood pressure device.
On 08/09/2023 at 8:30 AM, V9 (License Practical Nurse/LPN) entered R13's room with the blood pressure
device and placed the blood pressure cuff on R13's arm to obtain the blood pressure reading of 143/79. V9
(LPN) returned to the medication cart with the blood pressure device to prepare R13's medications. V9 did
not clean the blood pressure device.
On 08/09/2023 at 8:37 AM, V9 (License Practical Nurse/LPN) located inside of R179's room with the blood
pressure device and placed the blood pressure cuff on R179's arm to obtain the blood pressure reading of
150/65. V9 did not clean the blood pressure device.
On 08/09/2023 at 8:41AM, V9 takes the blood pressure device and placed the blood pressure cuff on R51's
arm, who is located in the same room as R13 and R179. V9 did not clean the blood pressure device. V9
observed exiting R51's room and states R51's blood pressure reading did not register on the blood
pressure device, I have to take R51's blood pressure reading manually. V9 did not clean the blood pressure
device.
On 08/10/2023 at 10:50AM, V2 (Director of Nursing/DON) stated that reusable equipment such as blood
glucometers and blood pressure cuff devices should be disinfected in between resident use and that if not
performed, then infections can potentially be spread from resident to resident. V2 stated that reusable
devices are cleaned with bleach wipes according to the label/manufacturer's guidelines for
cleaning/disinfecting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 12 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Facility policy undated, titled Cleaning and Disinfection of Resident Care Equipment documents in part, V.
Reusable items (equipment that is designated reusable by more than one resident) are cleaned and
disinfected or sterilized between residents.
Facility policy dated 12/31/2022, titled Glucometer Infection Control Policy documents in part, 4. While
wearing gloves, the blood glucose monitor will be thoroughly cleaned and disinfected after each use per
manufacturer's guidelines.
Per record review, facility document of Bleach Wipe label document in part 5. Apply towelette and wipe
desired surface to be disinfected. A 30 second contact time is required to kill the bacteria and viruses on
the label except a 1 minute contact time is required to kill Candida albicans and Trichophyton interdigitale,
and a 3 minute contact time is required to kill Clostridium difficile spores. Reapply as necessary to ensure
that the surface remains visibly wet for the entire contact time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 13 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of observation, interview, and record review, the facility failed to follow policy on Antibiotic
Stewardship Program on tracking antibiotic use of all residents taking antibiotics and indication of antibiotic
use by prescriber for 3 out of 5 residents (R41, R49, and R228) reviewed for antibiotic stewardship.
Residents Affected - Few
These failures have the potential to affect 3 residents (R41, R49, and R228) with the risk of developing
resistance with antibiotic.
Findings include:
Per review of facility's July 2023 Antibiotic Tracking, 3 residents (R41, R49, and R228) taking antibiotic were
not included in the tracking log.
R41 has multiple antibiotic use that includes:
Levaquin 250 MG to give 1 tablet by mouth in the afternoon for ESBL (Extended-spectrum
Beta-Lactamases) of urine for 1 week until 04/06/2023.
Nitrofurantoin Macrocrystal Oral Capsule 100 MG Give 1 capsule by mouth two times a day for ESBL of
urine until 04/06/2023.
CefTRIAXone Sodium Injection Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for
antibiotic for 4 Weeks order date 5/2/2023 to 5/30/2023.
Ampicillin-Sulbactam Sodium Intravenous Solution Reconstituted 1.5 (1-0.5) GM Use 1.5 gram
intravenously every 6 hours for UTI (Urinary Tract Infection) for 4 Weeks order date 6/9/2023 until 7/3/2023.
On 08/08/2023 at 11:55 AM, R41 was seen alert and verbally able to express his thoughts. R41 has 2
urinals hanging on the right-side rails of his bed. R41 said, I still have discomfort during urination, and
frequently urinating during night.
R41 has multiple antibiotics for UTI (Urinary Tract Infection) including ESBL (Extended-spectrum
Beta-Lactamases) in urine. Per CDC information on ESBL dated 11/22/2019, Enterobacterales can
produce enzymes called extended-spectrum beta-lactamases (ESBLs). ESBL enzymes break down and
destroy some commonly used antibiotics, including penicillins and cephalosporins, and make these drugs
ineffective for treating infections.
R41's care plan on Enhanced Barrier Precautions reads: R41 is at risk of acquiring MDRO (Multi-Drug
Resistant Organism).
Per DPH Multi-Drug Resistant Organism Toolkit for LTC (Long Term Care) dated 08/2019, it reads:
When a drug that can normally be used to treat an infection does not work to treat the organism causing
the infection, the organism is called resistant to that drug. Multidrug-resistant organisms (MDROs) are
organisms or microbes that have become resistant to multiple types of drugs that are normally used to treat
them. MDROs can include fungi, viruses, and parasites, but many are bacteria.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 14 of 15
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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 0881
Level of Harm - Minimal harm
or potential for actual harm
Antimicrobial resistance is the ability of these microbes to resist the effects of drugs - that is, the germs are
not killed, and their growth is not stopped. One type of antimicrobial resistance is antibiotic resistance,
when bacteria are resistant to the antibiotics used to treat them.
R49 has orders for antibiotics:
Residents Affected - Few
Ertapenem Sodium 1 GM intravenous solution for UTI (Urinary Tract Infection) for 5 days. Although it was
ordered for 5 days, ordered date was 7/18/2023 and was discontinued the next day 7/19/2023.
Invanz 1 GM intravenous solution with order date 7/19/2023 to 7/22/2023.
All of these antibiotic order by physician were not included in the antibiotic tracking for the month of July.
R228 has antibiotic order for Metronidazole 500 MG every 8 hours for C. Diff (Clostridioides difficile) is a
bacterium that causes diarrhea and colitis (an inflammation of the colon). C. diff infection can be
life-threatening. R228's antibiotic was not included in the antibiotic tracking for the month of July.
08/09/2023 at 09:40 AM, V2 (Infection Preventionist / Director of Nursing) said, There are antibiotics that
does not have indication what it is being used for, and it needs clarification. Yes, all residents that are taking
antibiotics must be included in the tracking form to monitor effectivity, adverse reaction of antibiotic use.
Policy for Antibiotic Stewardship Program dated 10/15/19, reads:
To limit antibiotic resistance in the post-acute setting, improve treatment efficacy and resident safety, and
reduce treatment-related costs. The Antibiotic Stewardship Program (ASP) is designed to promote
appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the
possible of adverse events associated with antibiotic use. Under tracking the IP (Infection Preventionist) will
be responsible for infection surveillance and MDRO tracking.
Policy for Antibiotic Stewardship Program not dated, reads:
Requires prescribers to document a dose, duration, and indication for all antibiotic prescription. Monitor
rates of C. Diff infection, antibiotic-resistant organisms, and adverse drug reactions due to antibiotics.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 15 of 15
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
23 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
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.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Fpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the August 11, 2023 survey of PAUL HOUSE & HEALTH CR CTR?
This was a inspection survey of PAUL HOUSE & HEALTH CR CTR on August 11, 2023. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PAUL HOUSE & HEALTH CR CTR on August 11, 2023?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
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 . If you believe any information is inaccurate, report it here.