Health inspection·November 16, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10. 9/14/2023 at 0600 Levalbuterol HCL Inhalation Nebulization Solution 1.25mg(milligrams)/3ml(milliliters)-1 vial inhale orally via nebulizer every 8 hours. 11. 9/6/2023 at 0600 Brinzolamide Ophthalmic Suspension 1% -Instill 1 drop in both eyes three times a day. 12. 9/6/2023 at 0600 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 13. 9/14/2023 at 0600 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 14. 9/6/2023 at 0600 Pantoprazole Sodium Oral Tablet Delayed Release 40mg-Give 1 tablet by mouth one time a day. 15. 9/14/2023 at 0600 Pantoprazole Sodium Oral Tablet Delayed Release 40mg-Give 1 tablet by mouth one time a day. 16. 10/1/2023 at 0600 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 17. 10/6/2023 at 0600 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 18. 10/1/2023 at 0600 Pantoprazole Sodium Oral Tablet Delayed Release 40mg-Give 1 tablet by mouth one time a day. 19. 10/6/2023 at 0600 Pantoprazole Sodium Oral Tablet Delayed Release 40mg-Give 1 tablet by mouth one time a day. 20. 10/1/2023 at 0000 Levalbuterol HCL Inhalation Nebulization Solution 1.25mg(milligrams)/3ml(milliliters)-1 vial inhale orally via nebulizer every 8 hours. 21. 10/1/2023 at 0600 Levalbuterol HCL Inhalation Nebulization Solution 1.25mg(milligrams)/3ml(milliliters)-1 vial inhale orally via nebulizer every 8 hours. 22. 10/6/2023 at 0600 Levalbuterol HCL Inhalation Nebulization Solution 1.25mg(milligrams)/3ml(milliliters)-1 vial inhale orally via nebulizer every 8 hours. R2's diagnosis include but are not limited to, Acute On Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Chronic Respiratory Failure With Hypoxia, Weakness, Anemia In Chronic Kidney Disease, Chronic Kidney Disease, Stage 4 (Severe), Supraventricular Tachycardia, Essential (Primary) Hypertension, Elevated [NAME] Blood Cell Count, Unspecified, Unspecified Abdominal Pain, Hyperglycemia, Unspecified, Unspecified Atrial Fibrillation, Constipation, Unspecified, Acute Kidney Failure, Unspecified, Low Back Pain, Unspecified, Unspecified Fall, Subsequent Encounter, And Unspecified Glaucoma. R2's Brief Interview for Mental Status (BIMS) dated 10/13/2023 documents that R2 has a BIMS score of 13, which indicates that R2's cognition is intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145939 If continuation sheet Page 2 of 6 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 145939 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649 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 0684 Level of Harm - Minimal harm or potential for actual harm On 11/15/2023 at 12:30pm V2(Assistant Director of Nursing) presented R1's MAR (medication administration record) and POS (Physician Order Summary Report) which were reviewed by the surveyor. There were missing entries of nurses' signatures or codes on the MAR for November 2023(11/1/2023 to 11/30/2023) for the following dates, times, and medications: Residents Affected - Few 1. 11/1/2023 at 2100 Lipitor Tablet 10 mg(milligrams) - give 1 tablet by mouth at bedtime. 2. 11/4/2023 at 0600 Lidoderm Patch 5%- apply to lower back topically one time a day. 3. 11/8/2023 at 0600 Lidoderm Patch 5%- apply to lower back topically one time a day. R1's diagnosis include but are not limited to, Peripheral Vascular Disease, Unspecified, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Essential (Primary) Hypertension, Personal History Of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits, Abnormal Uterine And Vaginal Bleeding, Unspecified, Unspecified Osteoarthritis, Unspecified Site, Other Symptoms And Signs Concerning Food And Fluid Intake, Restlessness And Agitation, Unspecified Lump In Unspecified Breast, Acquired Absence Of Both Cervix And Uterus And Other Psychoactive Substance Abuse, Uncomplicated. R1's Brief Interview for Mental Status (BIMS) dated 09/11/2023 documents that R1 has a BIMS score of 07, which indicates that R1's cognition is severely impaired. On 11/15/2023 at 10:35am V8 (DON/Director of Nursing) stated the nurses are responsible for administering the medications to the residents. V8 stated a nurse's missing initials on a resident's medication administration record for a scheduled medication for a resident would indicate that the medication was not administered. V8 stated it is my expectation that the nurses are to use a code on the medication administration record if a scheduled dose of medication for a resident is not administered to the resident. V8 stated the code usually prompts the nurse to do a progress note and notify the doctor that the resident did not take the medication. On 11/15/2023 at 11:10am V11(LPN) stated the nurse is responsible for administering the medication to the residents. V11 stated if there are missing initials on the medication administration record this indicates the medication was not given by the nurse. V11 stated there are codes the nurse can use on the medication administration record if a scheduled medication is not administered to the resident. On 11/15/2023 at 11:36am V13(RN/Registered Nurse) stated the nurses are responsible for administering medications to the residents. V13 stated if there were missing initials on the medication administration record for a resident's scheduled dose of medication this would indicate that the medication was not given. V13 stated there are codes a nurse can use if a scheduled dose of medication has not been administered to a resident. Reviewed the Facility's Administering Medications policy dated 3/2014, reviewed 11/2020 which documents, in part, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Underneath Policy Interpretation and Implementation page 2- #19. The individual administering the medication must initial the resident's EMAR (electronic medication administration record) in the appropriate box after giving each medication and before administering the next ones. Reviewed Registered Nurse undated Job Description which documents, in part, Registered Nurse (RN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145939 If continuation sheet Page 3 of 6 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 145939 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649 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 0684 Essential Duties and Responsibilities: Maintains knowledge of necessary documentation requirements. Level of Harm - Minimal harm or potential for actual harm Reviewed Licensed Practical Nurse undated Job Description which documents, in part, Licensed Practical Nurse (LPN) Essential Duties and Responsibilities: Maintains knowledge of necessary documentation requirements. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145939 If continuation sheet Page 4 of 6 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 145939 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649 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 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 interviews and record review, that facility failed to ensure that one resident (R3) was free from pain, after a suspected unwitnessed fall. This failure affected one of 7 residents reviewed for pain management. Residents Affected - Few Findings include: R3 is [AGE] year old with diagnosis including but not limited to: History of falling, Intervertebral disc degeneration, Cervical disc degeneration, Muscle wasting and atrophy, Ataxic gait and Hypertension. R3 has a BIMS (Brief Interview of Mental Status) score of 3 which indicates severe cognitive impairment. On 11/13/23 during investigation, V2 (Assistant Director of Nursing) said, R3 was discharged after going out to the hospital. She (R3) was complaining of pain and the family requested that she (R3) be sent to hospital for further evaluation. On 11/15/23 at 10:45 AM, V8 (Director of Nursing) said, I was not aware of R3 stating that she had a fall or complaining of pain. Surveyor inquired about the expectations regarding falls and pain management. On 11/15/23 at 10:45 AM, V8 said, If a resident has a suspected fall, the nurse conducts a post fall assessment, risk management, take vitals, call the family, call the Doctor and notify me (V8). For a patent that is non-verbal or cognitively impaired, a non-verbal pain scale is used to assess for facial grimacing, moaning etc. Surveyor inquired about expectations regarding pain management. On 11/15/23 at 10:50 AM, V8 said, If there is prn (as needed) pain medication it should be administered to the resident complaining of pain. If there is no order for pain medication, an order should be obtained and administered. If the resident's pain is not addressed, it could lead to anxiety, increased blood pressure, and continued pain until it's addressed. Surveyor asked how administered medications are documented. On 11/15/23 at 10:50 AM, V8 said, Pain medication is documented in the MAR (Medication Administration Record). If it is a one-time order it would also be documented on the MAR.Pain assessments are also documented on the MAR and would indicate a checkmark for no pain and a number would indicate the level of pain. On 11/15/23 at 2:50 PM, V16 (Certified Nurse Assistant/ CNA) said, I am familiar with R3. I worked with her the day that she kept saying that she fell and I told the nurse. I did not witness R3's fall, but there was a change in her (R3). I (V16) have been working at the facility for a long time and I know when there is a change in a patient. R3 kept ringing her call device and seemed uncomfortable. R3 kept saying that she fell. When the family came in, they were upset because R3 was still complaining that she had a fall days before and was complaining of leg pain. The family asked that R3 be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145939 If continuation sheet Page 5 of 6 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 145939 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649 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 0697 sent to the hospital because of the leg pain. Level of Harm - Minimal harm or potential for actual harm Surveyor called V6 (Licensed Practical Nurse/ LPN) on 11/14/23 and 11/15/23, but no answer. Residents Affected - Few Facility incident report completed on 4/6/23 by V6 (LPN) documents, Resident stated she had a fall on Tuesday (4/4/23). Facility Abuse Investigation statement by V16 CNA documents, R3 stated that she had a fall when asked to stand and get into the bed. Once R3 was in bed, R3 kept ringing her light to be turned on her side. R3 stated again the she fell. Nursing Note written by V6 on 4/6/23 documents, Resident complained of having leg pain, family requesting to send to Hospital for evaluation. Writer made aware by family that R3 had a fall on Tuesday. Pain Assessment completed on 4/6/23 documents a pain level of 6 out of 10. R4's POS (Physician Order Sheet) excludes any order for pain medication. R4's MAR (Medication Administration Record) excludes any administration of pain medication between 4/1/23 through 4/30/23. R3's Care Plan (cancelled after hospital admission) documents, R3 has potential risk for alteration in comfort related to advanced disease process, chronic physical disability including diagnosis of Intervertebral Disc, Thoracic Region, Cervical Disc Degeneration, History of Wedge Compression Fracture Lumbar Vertebrae, Muscle Atrophy, History of CVA (Cerebral Vascular Accident), Interventions: Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Facility document titled Pain- Clinical Protocol documents, the physician or LIP (Licensed Independent Practitioner) will order appropriate non-pharmalogic and medication interventions to address the individual's pain; the staff will reassess the individual's pain and related consequences at regular intervals; Review should include frequency, duration and intensity of pain, ability to perform activities of daily living, sleep pattern, mood, behavior, and participation in activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145939 If continuation sheet Page 6 of 6