Health inspection·January 11, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to follow pain management policy related to documentation of pain, assessment of pain, and following physician order in giving pain medication for 1 out of 4 residents (R2) reviewed for pain management. Residents Affected - Few Findings include: R2 was [AGE] years old, with diagnosis of intervertebral disc disorders with radiculopathy, lumbar region, arthritis, low back pain. R2 was initially admitted on [DATE]. Per resident record on 10/14/2023 at 2:07 PM, R2 was discharged against medical advice. R2's handwritten notes read as follows: due to arthritis, back and neck pain, laminectomy surgery (10/3/2023) leg pain management. R2 has incision on her lower back. To give Hydrocodone Acetaminophen (Norco) 10 - 325 MG (milligrams)every 4 hours or round the clock. On 12/19/2023 per V3 (Director of Nursing) this document is used by nurses during admission getting instructions from the hospital. Before arriving in the facility, hospital record monitoring pain of R2 dated 10/13/2023 were documented as follows: At 2:46 AM pain intensity of 8 out of 10, At 4:07 AM pain intensity of 10 out of 10, At 5:00 AM pain intensity of 8 out of 10, At 5:07 AM pain intensity of 8 out of 10, At 7:57 AM pain intensity of 8 out of 10. (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 2 Event ID: 145796 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 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 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)