Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide transportation for a resident (R1) who required daily
methadone clinic visits. This failure affected one of three residents reviewed for quality of care.
Residents Affected - Few
Findings include:
R1's face sheets shows that R1 admitted to the facility on [DATE]
R1's progress note dated May 24, 2024, authored by V5 (Social Service Director) documents in part that
R1 discharged from the facility Against Medical Advice (AMA) on May 24, 2024.
R1 has a diagnosis which include but not limited to opioid dependence, uncomplicated, psychoactive
substance abuse, depression, and chronic diastolic congestive heart failure.
R1's Minimum Data Set (MDS) dated [DATE] shows that R1 did not have a Brief Interview for Mental Status
score and indicated that R1's memory was ok.
R1's hospital record Physician Order Sheet (POS) dated 05/18/24 shows that R1 has orders to receive
Methadone HCl Oral Tablet 10 MG by mouth starting May 19, 2024.
On 06/11/24 at 11:03 am, V2 (Director of Nursing, DON) stated that R1 admitted to the facility with orders
to receive Methadone daily. V2 stated that R1's methadone was to be dispensed at the methadone clinic
daily and that R1 required transportation to the methadone clinic. V2 explained that R1 admitted to the
facility the evening of Saturday May 18, 2024, and that the Methadone clinic was closed. V2 then explained
Sunday May 19, 2024, that the Methadone clinic was closed. V2 then explained on Monday May 20, 2024,
the floor nurse called the Methadone clinic to arrange for R1 to come to the methadone clinic and that R1
was not able to be transported to the methadone clinic Monday May 20, 2024. V2 further stated on Tuesday
May 21, 2024, V2 did not know why R1 was not transported to the Methadone clinic. V2 then explained on
May 22, 2024, R1 was transported to the Methadone clinic and received Methadone. V2 explained that the
Methadone clinic administered R1 Methadone, did not dispense R1 any Methadone, and required R1 to
come to the Methadone clinic daily. Next, V2 stated that on Thursday May 23, 2024, there was no
transportation available for R2 to transport to the Methadone clinic. V2 then explained on May 24, 2023, R1
was told that R1 would be transported to the Methadone clinic and that R1 did not want to wait for the
transportation at the facility and that R1 left the facility against medical advice (AMA). When V2 was asked
regarding the importance of residents being transported to the residents scheduled appointments V2 stated
that it is very important and that V1 (Administrator) was not at the facility to approve a private transportation
for R1.
(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:
145939
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
06/13/2024
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
Residents Affected - Few
On 06/11/24 at 11:51 am, V6 (Registered Nurse, RN) stated that V6 was R1's nurse at the facility. V6 stated
that R1 admitted to the facility with orders to receive Methadone 10 mg (milligrams) oral tablet by mouth
daily. V6 stated that R1 never had Methadone available at the facility to administer to R1. V6 stated that V6
remembers R1 going to the Methadone clinic once while R1 was at the facility but doesn't know if the
Methadone clinic administered R1's Methadone. V6 stated that V6 made V2 (Director of Nursing, DON)
aware that R1 did not have Methadone at the facility. V2 then explained that R1 left the facility against
medical advice (AMA).
On 06/11/24 at 2:51 pm, V10 (Transportation Coordinator) stated that V10 is the facility's transportation
coordinator, central supply coordinator, medical records coordinator, and fills in as the front desk
receptionist as needed. V10 explained the facility has a transportation book on each floor that the floor
nurse documents the residents transportation appointments. V10 stated that V10 does not check the
transportation book every day and that V10 checks the transportation book 2-3 times per week when V10 is
able to. V10 explained when V10 checks the transportation book V10 will ask the floor nurse if the residents
need a stretcher in order to determine if V10 will arrange the outside source transportation company to
transport the resident. V10 further explained if a resident is ambulatory or in a wheelchair, V10 schedules
the facility's transportation van to transport the resident to the residents appointment. When V10 was asked
regarding R1's transportation to R1's daily methadone appointments V10 stated that V10 recalls R1 going
to R1's daily methadone appointments once while R1 was at the facility. V10 explained that R1 admitted to
the facility on a Saturday and that V10 was informed regarding R1's methadone clinic appointment on a
Monday. V10 stated that nursing department informed V10 that the nursing department was arranging R1's
daily methadone clinic appointment. V10 then stated the next day on Tuesday, V10 stated that the facility's
transportation van was booked and that V10 could not arrange R1 to transport to the methadone clinic.
When V10 was asked regarding making R1 other transportation arrangements, other than the facility's van
V10 stated, It takes the residents insurance three days to approve a transportation appointment and R1 still
would not have been able to go to R1's methadone appointment that Tuesday. V10 then stated on
Wednesday R1 went to R1's methadone clinic appointment via the facility's transportation van. Next, V10
stated on Thursday R1 was not transported to R1's methadone clinic appointment because the facility's
transportation van was booked. Then V10 explained on Friday R1 did not transport to R1's methadone clinic
appointment and R1 discharged from the facility against medical advice (AMA). When V10 was asked
regarding the importance of residents being transported to the residents scheduled appointments V10
stated that it is very important and that V10 is overseeing several departments at the facility.
R1's Medication Administration Record (MAR) dated May 2024 shows that R1 did not receive Methadone
HCl Oral Tablet 10 MG by mouth for treat addicted heroin on May 19, 2024, May 20, 2024, May 21, 2024,
May 22, 2024, May 23, 2024, or May 24, 2024.
R1' s care plan dated canceled date 05/28/24 documents in part: 'Focus: R1 has history of substance
use/abuse/chemical dependency related to: Allowing negative, inappropriate persons to influence R1 and
R1's use of substances. R1 has a diagnosis of Opioid Dependence.'
The facility's policy and procedure for dated 08/12/23 and titled Community Methadone documents in part:
Purpose: To ensure coordination of care for residents requiring Methadone in the community. Policy: 1. All
residents that are admitted to the facility with needs for Methadone will have coordination of services
between the facility and the Methadone Clinic prior to admission. 2. Methadone services will be set up with
the methadone clinic by the local hospital or community agency prior to the resident's admit to the facility.
When the methadone schedule is determined, the facility will set up transportation arrangements.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145939
If continuation sheet
Page 2 of 3
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
06/13/2024
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
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's policy dated 11/2020 titled Administering Medication documents in part Policy Statement:
Medication shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and
Implementation: 3. Medications must be administered in accordance with the orders including any required
time frame that is indicated specifically in the order by the physician.
The facility's undated policy titled Transportation documents, in part: Policy Statement: Our facility will assist
residents in arranging transportation to/from diagnostic appointments when necessary. Policy Interpretation
and Implementation: 3. Should it become necessary for the facility to provide transportation, the
transportation coordinator will be responsible for arranging the transportation through the business office.
Event ID:
Facility ID:
145939
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the June 13, 2024 survey of PAVILION OF SOUTH SHORE?
This was a inspection survey of PAVILION OF SOUTH SHORE on June 13, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PAVILION OF SOUTH SHORE on June 13, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.