Health inspection·May 29, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records the facility failed to provide and/or obtain routine medication for availability in the medical supply for 1 out of 3 residents (R2) reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R2) that may impede timely administration and adversely affecting a resident's condition due to delay of acquisition of a medication. Findings include: R2 is [AGE] years old, initially admitted in the facility 12/10/2016. R2 diagnosis includes legal blindness, Parkinson's disease with dyskinesia, major depression, and dry eye syndrome. R2 has an order by physician to receive Latanoprost Ophthalmic Solution eye drops scheduled to be given at 07:00 PM, one (1) drop both eyes for legal blindness. On 05/27/2025 at 12:56 PM, R2 was seen alert and able to express thoughts within topic. R2 stated that he must ask for his eye drops before he can receive it. R2 said, Eye drops, I must ask for them. No, I don't receive my eye drop if I did not ask. I received them before I go to bed. And in the afternoon too. R2 said that he is legally blind because he sees things double instead of single form. At the nurse station with V4 (Licensed Practical Nurse) and V5 (Licensed Practical Nurse), medication cart that stores R2's medication was reviewed with V5. V5 checked all drawers and compartments but unable to find R2's Latanoprost Ophthalmic Solution eye drop. V5 informed V2 (Director of Nursing) who went to check the medication cart with V4, unable to find R2's eye drop. V2 went with V3 (Assistant Director of Nursing) to another floor where pharmacy medication dispenser was located. V3 checked supplies of medication for R2 specific to Latanoprost Ophthalmic Solution eye drop. V3 stated that R2's eye drop was not available, then called pharmacy to ask for details related to Latanoprost Ophthalmic Solution medicine. V3 stated that according to pharmacy, it was delivered to the facility on [DATE]. V2 stated that pharmacy should have been informed about R2's eye drops because electronic system automatically informs the pharmacy. V2 stated that in case pharmacy does not deliver medication for residents. It is the responsibility of nurses to request pharmacy to deliver specific medication in order not to run out of stock. V3 provided documentation from pharmacy dated 05/04/2025 that Latanoprost Ophthalmic Solution eye drops for R2 was delivered on the same date (05/04/2025). Per document, Latanoprost Ophthalmic Solution eye drops have a quantity of 25 uses. Medication Administration Record (MAR) for May 2025 documents that Latanoprost Ophthalmic Solution eye drops has a schedule to be given at 07:00 PM, one (1) drop both eyes for legal blindness. It was recorded as administered daily including date of delivery 05/05/2025 to current date 05/26/2025 or 22 days of use. (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 05/29/2025 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)