Health inspection·February 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement fall prevention interventions for one (R1) of three residents reviewed for falls. This failure resulted in R1 falling on 02/08/2025 and R1 is hospitalized at the time of this survey. Findings include: R1's face sheet dated 09/15/2024, documents that R1 is a [AGE] year-old resident with diagnoses not limited to: unspecified intellectual disabilities, down syndrome, unspecified, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, nontraumatic subarachnoid hemorrhage, unspecified, traumatic subdural hemorrhage without loss of consciousness. R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 04/15, indicating that R1 has severely impaired cognition. On 02/08/25, 10:37 AM, V3 (Registered Nurse) states that R1 fell this morning at approximately 9:50 AM. V3 continues to state my CNA (certified nursing assistant) was in the room with her. R1 was walking barefoot. The CNA (V4) told her to go back and get your shoes.When she turned, she lost balance and she fell. V3 reports that V4 called V3 and V3 states that she went to the room and found R1 sitting on the floor, on her bottom. V3 states that V4 reported to her that R1 did not lose consciousness. V3 states that R1 didn't report anything, of what happened. She denied pain and had no visible injuries. V3 adds that V4 did inform V3 that R1 did hit her head on the door. V3 states that she is familiar with R1's care and is usually R1's regular nurse in the morning shifts. V3 reports that R1 has down syndrome, she is ambulatory, but lately she has been more confused, and we must redirect her more. Lately she has become a feeder. We present her with the tray, set her up, and encourage her to eat. She will say yes, but then not eat. So now she is a feeder. V3 reports that staff try to monitor R1 and do try to get her in the day room. We have someone in the day room and have yellow tape which means they are fall risk, by her name. V3 reports that R1 does not use any assistive devices. V3 states that R1's gait is steady, sometimes she gets distracted very easily. If she is walking and if you call her, she can turn fast. Lately she has been going into other residents' rooms. She usually doesn't go, but lately she has been presenting with these behaviors. On 2/08/25, 11:05 AM, V4 (Certified Nursing Assistant) states that she reads the residents' electronic medical record to know the residents' needs. V4 continues I ask the nurses that know the residents and ask them how I can help them. In the POC, there is person information that tells you the basic needs that they need assistance with. V4 reports that R1 needs help with showering, going to the toilet because she cannot clean herself. V4 states that R1 needs help with eating, sometimes she can (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 3 Event ID: 145792 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 145792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of Logan Square, The 2242 North Kedzie Chicago, IL 60647 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)