Health inspection·January 17, 2025

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. Based on observations, review of records, and interviews the facility failed to safeguard resident rights to properly account and correctly charge resident funds for 7 out of 9 residents (R2, R4, R5, R7, R8, R9, and R10. These failures does not conform with their policy that mandate the facility to hold, safeguard, manage and account resident funds. Four (4) residents (R2, R4, R7, and R8) personal funds accounts were affected and charged dental insurance premiums that should have been included in care cost. 5 residents (R2, R5, R8, R9, and R10) were charged haircuts on their resident funds without proper documentation of consent, residents unable to give consent due to impaired cognition, and/or service date discrepancies. Findings include: On 01/14/2025, at 1:07 PM, V3 (Assistant Administrator) stated that dental insurance premiums were charge by increasing resident's allowance (care cost) credit to accommodate dental insurance premiums. Per V3, dental insurance premiums is part of care cost and not to be charged differently. V3 stated that starting January 2024 there was an increase from 30 dollars to 60 dollars on personal need allowance. Residents that are not under SSI (Supplemental Security Income) should get 60 dollars monthly. Review on R2, R3, R4, R5, R6, R7, R8, R9, and R10's resident fund accounts from January 2024 to January 2025 are as follows: R2 has the following accounting of his resident funds: Charges include dental insurance premiums of $199.36 dollars on 05/14/24, 08/05/2024, and 10/03/2024. $996.80 dollars was charged on 01/07/2025. A credit by way of reduction of care cost of $199.36 dollars was given on 12/5/24 and 01/10/25. R2's total charges or deduction on his account for dental insurance premiums resulted to $1,594.88 dollars. R2's total credit by reduction of care cost resulted to $398.72 dollars. With difference of $1,196.16 dollars charged or deducted to R2's account. R2 also has charges for Beauty Shop / Barber of $10.00 dollars on 01/10/25. R4 has the following accounting of her funds: Charges include dental insurance premiums of $199.36 dollars on 08/05/2024 and 10/03/2024. $996.80 dollars on 01/07/2025. A credit by way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R4's total charges or deduction on her account for dental insurance premiums resulted to $1,395.52 dollars. R4's total credit by reduction of care cost resulted to $398.72 dollars. R4 had a difference of $996.80 dollars charged or deducted to R4's fund. R5 has the following accounting of her funds: No personal needs allowance credited to resident's Page 1 of 7 145792 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fund balance for 02/2024. R5 also has charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024 and 09/06/2024. R7 has the following accounting of her funds: Charges includes dental insurance premiums of $199.36 dollars on 08/05/2024 and 10/03/2024. On 1/07/2025, R7 has a charge of $996.80. A credit by way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R7's total charges or deduction for dental insurance premiums $1,395.52 dollars. R7's total credit by reduction of care cost resulted to $398.72 dollars, with a difference of $996.80 dollars charged or deducted to R7's fund. R8 has the following accounting of her funds: Charges includes dental insurance premiums of $199.36 dollars on 10/03/2024 and $598.08 dollars on 01/07/2025. A credit by the way of reduction of care cost of $199.36 dollars on 12/05/2024 and 01/10/2025. R8's total deduction for dental insurance premiums was $797.44 dollars. R8's total credit by reduction of care cost resulted to $398.72 dollars, with a difference of $398.72 dollars charged or deducted to R8's fund. R8 has charges for Beauty Shop / Barber of $15.00 dollars on 09/06/2024 and 01/10/2025. R9 has the following accounting of her funds: R9 has charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024. R10 have the following accounting of her funds: R10 has also charges for Beauty Shop / Barber of $10.00 dollars on 02/06/2024, 09/06/2024 and 01/10/2025. In summary, there are four (4) residents that have charges on their dental insurance premiums. The funds were deducted from the personal funds account more than what was credited. R2's dental insurance premiums total charges was $1,594.88 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R2's account has remaining charges of $1,196.16 dollars that needs to be credited back to his account. R4's dental insurance premiums total charges was $1,395.52 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R4's account has remaining charges of $996.80 dollars that needs to be credited back to her account. R7's dental insurance premiums total charges was $1,395.52 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R7's account has remaining charges of $996.80 dollars that needs to be credited back to her account. R8's dental insurance premiums total charges was $797.44 dollars, with a total credit in a form of care cost reduction of $398.72 dollars. R7's account has remaining charges of $398.72 dollars that needs to be credited back to her account. Beauty shop or barber charges: R2's resident fund account was charged $10.00 dollars on 1/10/25. R5's resident fund account was charged $10.00 dollars on 02/06/2024 and 09/06/2024. R8's resident fund account was charged $15.00 dollars on 09/06/2024 and 01/10/2025. 145792 Page 2 of 7 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0571 R9's resident fund account was charged $10.00 dollars on 02/06/2024. Level of Harm - Minimal harm or potential for actual harm R10's resident fund account was charged $10.00 dollars on 02/06/2024, 09/06/2024 and 01/10/2025. Residents Affected - Some On 01/15/2025, at 1:50 PM, V3 (Assistant Administrator) was informed on multiple residents having discrepancies on the amount of dental insurance premium deducted compared to the care cost credited to their resident funds account. There are multiple charges of beauty shop or barber charges to multiple residents. V3 took note on those residents (R2, R4, R7 and R8) and stated that she will review each of their resident fund's account. V3 stated that with regards to barber or beauty shop charges she will check on documentation that residents have written agreement on payment of those services and will get back for answers. On 01/16/2025, at 9:23 AM, with V12 (Business Manager) after review of R2's resident fund account from January 2024 to January 2025, V12 stated, what happened was room and board or care cost accounting needs to be changed. V12 said, I will reach out to our corporate biller to adjust the money. Dental insurance premiums should come from room and board or cost of care, it should be credited back. V12 stated that she does not know how far back the corporate biller can change the audit form (resident fund account itemization). V12 was informed that R4, R7 and R8's dental premium insurance charges are also more than what were credited on their respective resident fund accounts. V12 said, Moving forward, we need to audit the whole account of all the residents. Not only those that you identified. V12 was asked, why were there different charges for dental premiums that includes an amount of $996.80 dollars instead of $199.36 dollars. V12 stated that in the past there was nobody to address the problem. Dental premiums should be taken out monthly, not an accumulation of five (5) months. At 10:25 AM, V3 (Assistant Administrator) was made aware about the concerns that were identified related to resident funds of R2, R4, R7, and R8 during conversation with V12. V3 stated that she will look into the matter. Surveyor followed up with V3 related to charges on resident funds for beauty shop or barber. On 01/16/2025, at 12:55 PM, V3 (Assistant Administrator) provided documents related to resident's haircut services that was deducted to their personal funds. In comparison, all date of services in the documents provided by V3 does not match the date of services on resident funds statement. V3 wrote the date charges were made or debited to indicate a referral date. The following discrepancies were identified: R2's resident funds statement documents that $10.00 dollars was debited to R2's account on 01/10/2025, with date of service of 01/09/2025. But the signed document by V4 (Activity Director) as a witness and without R2's signature date of service was on 12/16/2024. R5's resident funds statement documents that $10.00dollars was debited on 02/06/2024 with the same date of service of 02/06/2024. The signed document by V4 as a witness and without R5's signature date of service was on 02/01/2024. Another deduction of $10.00 dollars was made on 09/06/2024 with service date of 09/03/2024. The signed document by V4 as a witness and without R5's signature does not indicate any date. R8's resident funds statement documents that $15.00 dollars was debited to R8's account on 01/10/2025, with date of service of 01/09/2025. But the signed document by V4 (Activity Director) as a witness and without R8's signature date of service was on 12/16/2024. Another deduction of $15.00 dollars was made on 09/06/2024, with service date of 09/03/2024. document was signed by V4 as a witness and without R8's signature does not indicate any date. 145792 Page 3 of 7 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R9's resident funds statement documents that $10.00 dollars was debited to R9's account on 07/08/2024, with date of service of 07/06/2024. But the signed document by V4 (Activity Director) as a witness and was without R9's signature date of service was on 06/13/2024. R10's resident funds statement documents that $10.00 dollars was debited to R10's account on 02/06/2024, with the same date of service of 02/06/2024. But the signed document by R8 with a date of service was on 01/18/2024. Another deduction of $10.00 dollars was made on 09/06/2024, with service date of 09/03/2024. The signed document by R10, and the date of service was on 08/08/2024. Another deduction of $10.00 dollars was made on 01/10/2025 with service date of 01/09/2025. But the signed document by R10 with service date of 12/16/2024. V3 was informed about discrepancies on service date of resident funds statements compared to actual service done per signed documents. V3 stated that residents date of service on their personal fund does not match date of service on their signed form. V3 said It should match, I know what you mean. R2 date has like a month difference. V3 said that moving forward, the facility needs to improve their auditing on personal funds, that is why V11 (Business Manager) is there. V15 (admission Assistant) will help V11. V3 was asked why there are charges that were signed by V4 as a witness without the signature of resident. V3 replied, They just put an X on it (pointing to R2's name on document). On 01/16/2025, at 2:59 PM, V4 (Activity Director) stated that it is her signature that appears on the document that charges residents for their haircut. V4 stated that R5 sometimes understands and sometimes does not understand. When asked if R5 can give consent on paying for his haircut from his personal fund, V4 stated that R5 agrees to have his haircut but sometimes he cannot give consent. V4 was also asked about R8's haircut and whether or not R8 agrees to pay for his haircut through his personal fund. V4 stated, R8 can give consent to get a haircut, but I am not sure if he can give consent that it will be deducted to his account. V4 stated that R8's friend knows that he will get a haircut. But she did not say to R8's friend that it will be deducted to R8's account (resident funds). Both R5 and R8 has a BIMS (Brief Interview of Mental Status) of six (6) that indicates both R5 and R8 have severe cognitive impairment. Document provided by facility that reflects charges of haircuts of multiple residents have signatures of V4 that reads witness by (signature of V4). Multiple residents that were signed by V4 does not indicate resident signatures but has charges for haircuts. On 01/14/2025, at 11:45 AM, R5 was seen in his room and during the meeting, R5 was not able to answer questions about the topic. R5 has diagnosis of vascular dementia. At 12:09 PM, R8 was seen unable to answer to questions. R8 has a diagnosis of dementia with psychotic disturbance. On 01/16/2025, at 3:15 PM, with V2 (Director of Nursing) and V3 (Assistant Administrator). V3 was made aware of R5 and R8's inability to give consent on charges of resident fund accounts due to their limitation of cognition having a BIMS score of 6. V4 was signing as a witness to charge R5 and R8 on their resident funds. V3 stated that it will be hard for R5 and R8 to see other residents having haircuts and they are not given the same. V3 was made aware that it is not the haircut or the charges on the haircut in question. But the fact that it was charged to R5 and R8's resident fund because there are many modes of payment besides charging resident funds. Residents that are not able to give consent due to limitation of cognition have representatives or family members that can provide consent. V2 (Director of Nursing) stated that she understood because it is a common practice like getting consent to start psychotropic medication or getting consent for vaccination. Resident Trust Fund Policy dated 08/11/2011, reads: The purpose is for the facility to hold, safeguard, manage, and account for the personal funds of 145792 Page 4 of 7 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0571 the resident deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145792 Page 5 of 7 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to provide flu vaccine and education to two (R1, R11) residents of four reviewed. Residents Affected - Few Findings include: R11 is a [AGE] year-old individual admitted to the facility on [DATE]. R11's medical diagnosis includes but not limited to influenza due to identified novel influenza a virus with other respiratory manifestations, type 2 diabetes mellitus with diabetic chronic kidney disease, acute respiratory failure with hypoxia, cognitive communication deficit. R11's MDS (Minimum Data Set) section C dated [DATE], documents R11's Brief Interview for Mental Status (BIMS) as 15/15 indicating R11 has intact cognitive function. MDS section GG (Functional Abilities) documents R11 requires setup or cleaning assistance with eating and oral hygiene, partial to moderate assistance with toileting and is dependent for shower/bathing, upper and lower body dressing. Hospital records dated [DATE] document R11 presented to the hospital with two-day history of coughing and dyspnea, now admitted to Obs (observation) for further management after Rapid Plasma [NAME] (RPR) test, positive for influenza A. R1 is a [AGE] year-old individual admitted to the facility on [DATE] with medical diagnosis that include but not limited to type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris. R1's MDS (Minimum Data Set) section C dated De 30th, 2024, documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R11 has intact cognitive function. MDS section GG (Functional Abilities) documents R1 requires supervision/touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with toileting and shower/bathing. On [DATE], at 11:26 AM, V6 (Infection Control-Registered Nurse-RN) stated flu season monitoring starts from September to May of each year per CDC (Centers for disease control) protocol. V6 further stated in September of each year, she reaches out to residents and families to get flu vaccine consents so she can start vaccinating residents against the flu. V6 stated within 48-72 hours of a resident being admitted to the facility, she goes to the resident to discuss vaccination status and find out if the resident has received their immunizations. V6 stated some residents decline or agree to the vaccine. V6 stated she is supposed to provide education on the importance of flu vaccines and follow up with the residents to make sure they understand importance and make informed decisions regarding flu vaccinations.V6 stated when R1 was in the facility, her roommate, R11 had symptoms of a flu and was not feeling well, therefore, R11 was sent to the on hospital on [DATE]/2024 and was diagnosed with the flu. R11 returned to the facility on [DATE]. V6 stated R1 was moved to another room and R11 stayed in her room in isolation until R11's symptoms cleared. V6 stated R1 did not have a flu vaccine and V6 did not document that she offered R1 a vaccine or provided education to R1 regarding importance of flu vaccine. V6 stated If it is not documented, it is not done. V6 stated she did not document refusal in residents progress notes and did not go back to 145792 Page 6 of 7 145792 01/17/2025 Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few offer the flu vaccines later/date. V6 stated she offered R11 a flu vaccine but did not document it in R11's medical records. R11's refusal form is in V6's binder in her office and nurses do not have access to the binder since it is in V6's office in a drawer. V6 stated she should have offered flu vaccination information to R1 and R11 and followed up to make sure R1 and R11 understood importance of getting a flu vaccine and the education and refusal should have been part of R1 and R11's medical records where all medical staff can access to the information. V6 stated its important to offer flu vaccines to the elderly residents so that they don't get very sick if they contract the flu because of their age and other medical morbidities. Review of R1 and R11's immunization records do no not document R11's consent, refusal or education of flu immunizations. Review of 2024-2025 Resident Influenza Vaccine Consent documents: Seasonal Flu activity can begin as early as October and as late as May. Review of Facility Policy titled Influenza Policy titled 8/21 documents: -Vaccine should be ideally administered by the end of October but should continue to be offered as long as influenza viruses are circulating locally, and unexpired vaccine is available. 145792 Page 7 of 7