Health inspection·February 7, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy to ensure that call lights are within easy reach for two (R25, and R58) residents out of 8 residents reviewed for call lights in a sample of 23. Residents Affected - Few Findings Include: 1. R25's face sheet shows R25 is an [AGE] year-old male. R25's electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with diagnoses not limited to: Chronic obstructive pulmonary disease, age related nuclear cataract, left eye, blindness left eye, history of falling, presence of pacemaker, wedge compression fracture of third lumbar vertebra, anxiety disorder, and atrial fibrillation. 2. R58's face sheet shows R58 is a [AGE] year-old male. R58's electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, repeated falls, Chronic obstructive pulmonary disease, epilepsy, dizziness/giddiness, and hypertension. On 2/4/25 at 12:10 PM, R58 was observed in bed, and call light was under the bed. R58 stated that R58 could not reach the call light. V8 (Registered Nurse/RN) stated that R58's call light is not reachable because the call light is under the bed. V8 stated that R58's call light should be reachable so that R58 could call for help as needed. V8 stated that failure to keep the call light within reach could cause R58 to fall. On 2/4/25 at 12:22 PM, R25 was observed in bed, and the call light was not within reach. R25 attempted to reach the call light, R25 stated that R25 could not reach the call light because the call light is far from R25. V11 (Certified Nursing Assistant/CNA) stated that all call lights should be within reach, but R25 call light is not within reach. V11 stated that R25 would not be able to call staff for help to use the washroom and could cause skin breakdown. On 2/5/25 2:26 PM, V2 (Director of Nursing) stated that it is V2's expectation that staff will place the call light within the reach of the resident while in bed or in chair, and not under the bed. V2 stated that when staff fails to keep call light within reach, the need of the resident will not be met, and could lead to skin break down or fall for bed bound resident. R25's Minimum Data Set, dated [DATE] shows R25 is cognitively impaired. R25 functional assessment shows R25 requires extensive assistance with transfers and toileting. R58's Minimum Data Set, dated [DATE] shows R58 is moderately cognitively impaired. R58 functional assessment shows R58 requires Page 1 of 20 145939 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0558 assistance with transfers and toileting. Level of Harm - Minimal harm or potential for actual harm Facility's Policy titled: 'Answering the Call Light' dated 11/2013 documents in part: When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Residents Affected - Few 145939 Page 2 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to ensure code status should be consistent with plan of care and physician order for one (R29) resident reviewed for advance directives in a sample of 23. The findings include: R29's admission record documented initial admission date on [DATE] with diagnoses not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Dysarthria following cerebral infarction, Ataxia following cerebral infarction, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Unspecified osteoarthritis, Age-related osteoporosis without current pathological fracture, Foot drop right foot, Chronic kidney disease stage 3, Essential (primary) hypertension. On [DATE] At 1:01 pm V2 (Director Of Nursing / DON) stated each resident should have an advance directive whether DNR (Do not Resuscitate) or Full code and have an order. V2 said care plan should be developed for advance directives and make sure that resident's wishes are consistent or match with plan of care. She said if the code status is not consistent with plan of care and physician order, staff could make a mistake during emergency or could create confusion. V2 said staff could perform CPR (Cardiopulmonary Resuscitation) for resident who is DNR. On [DATE] At 10:09 am V6 (Social Service Director / SSD) stated Advance Directives include code status of the resident whether full code or DNR. She said it is important to determine the code status of every resident so when emergency arises staff would be able know what steps to make or proceed if to resuscitate or perform CPR (cardiopulmonary resuscitation) for full code or not to resuscitate resident if DNR is in place. V6 said code status needs an order and should be care planned. She said resident's wish for code status, physician order and care plan should match to avoid confusion and to properly care for the resident during emergency. MDS (Minimum Data Set) dated [DATE] showed R29's cognition was moderately impaired. R29's order summary report dated [DATE] with active order not limited to POLST (Physician Orders for Life-Sustaining Treatment): Do Not Attempt Resuscitation/DNR - Comfort Focused Treatment. R29's care plan documented in part: R29 requested to be a Full code. R29 requires all life saving measures and treatment in the event of any emergency. Perform CPR (Cardiopulmonary Resuscitation) for medical emergency if needed. Staff will inform caregivers of full-code status. R29's POLST form dated [DATE] showed DNR (Do Not Attempt Resuscitation), comfort measures only. Facility's Advance Directives policy dated 11/2020 documented in part: The plan of care for each resident will be consistent with his or her documented treatment preferences and / or advance directive. 145939 Page 3 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

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 Based on observation, interview and record review the facility failed to follow their peripheral inserted central catheter line dressing change policy, [A] failed change the line catheter dressing when not intact or compromised in any way, [B] failed to label the dressing with date or time, and [C] failed to enter physician orders of dressing changes and intravenous flush orders for one [R61] resident in a sample of 23. Residents Affected - Few Findings include: On 2/4/25 at 9:34 AM, Surveyor observed V8 [Registered Nurse] during medication administration observation. On 2/4/25 at 9:42A M, V8 obtained R61's blood pressure [103/69] with a manual blood pressure device that was on top of the medication cart. After use, V8 then placed the manual blood pressure device back on top the medication cart and did not sanitize the blood pressure device. Surveyor observed R61 resting in bed with left arm midline intravenous catheter dressing halfway lifted completely on one side with no date. V8 [Registered Nurse] stated, I noticed the midline dressing was completely lifted on one side, upon making rounds this morning around 7:30 AM, I have been busy and did not have the time to change the dressing. I am not sure when the midline dressing was last changed, there is no date on the dressing. On 2/4/25 at 1:40 PM surveyor observed the midline dressing was still lifted dressing on R61. V8 stated, I was busy but will change the dressing. On 2/4/25 at 1:43 PM V8 stated, There is no physician order placed for an intravenous catheter dressing change nor any flush orders. The intravenous catheter dressing change should be changed twenty-four hours after the line was inserted, every seven days and or when ever the dressing in not intact. I will place in the standing physician orders now. On 2/625 at 1:22 PM, V2 [Director of Nursing] stated, The midline intravenous or peripheral central catheter line catheter should have the dressing changed twenty-four hours after insertion, then every seven days and when ever the dressing is not intact or compromised in any way. Once the dressing is noted compromised the nurse should immediately change the dressing and label with date and time. If not, the compromised dressing could potentially cause an infection. There should be required physician orders for a mid or central line should include the following: dressing changes, flush orders, and monitor the site for infections should be on the resident's medication administration sheet. If the dressing is not labeled with date, time and there is no physician orders the nurses staff would not know the last time the dressing was changed, which could cause an infection. Policy document in part: Picc Line Dressing Changes dated 3/2014. The purpose of this procedure is to prevent catheter related infections associated with contaminated, loosened, or soiled catheter site dressings. Change picc/mid line catheter dressing twenty-four hours after catheter insertion, every seven days, or if it is wet, dirty, not intact, or compromised in any way. 145939 Page 4 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0684 The following information should be recorded in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Date and time dressing was changed. Residents Affected - Few 145939 Page 5 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review, the facility failed to follow plan of care and physician order to apply hand roll or splint on right hand for 1 (R29) resident. This failure could potentially affect 1 (R29) resident reviewed for range of motion in a sample of 23. The findings include: R29's admission record documented initial admission date on 12/3/18 with diagnoses not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Dysarthria following cerebral infarction, Ataxia following cerebral infarction, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Unspecified osteoarthritis, Age-related osteoporosis without current pathological fracture, Foot drop right foot, Chronic kidney disease stage 3, Essential (primary) hypertension. On 2/4/25 at 11:03 AM Observed R29 sitting up on wheelchair in the dayroom, alert and verbally responsive, right hand contracted, fist closed, no device in placed. On 2/5/25 At 1:01pm V2 (Director Of Nursing/ DON) stated splint / any device should be applied as ordered by physician to prevent contracture. She said it is important to follow resident's plan of care for splint / device use to prevent further contracture. On 2/5/25 At 1:47pm V14 (Restorative Nurse, LPN / Licensed Practical Nurse) stated R29 has contracture on right hand due diagnosis of Hemiplegia right dominant. She said R29 uses Right hand roll or resting splint from 8:30am to 12:30pm every day to prevent further contracture on right hand. V14 said if splint / hand roll was not applied as ordered by physician could potentially lead to further contracture. MDS (Minimum Data Set) dated 1/7/2025 showed R29's cognition was moderately impaired. She needed Substantial / maximal assistance with oral, toileting and personal hygiene, shower / bathe self, lower body dressing. MDS showed R29's had functional limitation in range of motion or impairment on side of the upper extremity (shoulder, elbow, wrist, hand). R29's order summary report dated 2/6/25 with active order not limited to May apply right hand roll / splint for 4 hours, then remove. R29's care plan documented in part: R29 needs to wear right hand splint daily for 4 hours. Apply hand roll to right hand. Replace hand roll as often as needed after patient removes. Facility's Range of Motion exercises / Splinting policy dated 10/2020 documented in part: The splint should be applied for time frame designated in physician order as tolerated. 145939 Page 6 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

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 observation, interview and record review, the facility failed to ensure that smoking materials (cigarette and lighters) were kept by staff for safety. This failure could potentially affect 3 (R28, R84, R93) residents reviewed for smoking in a sample of 23. The findings include: R28's admission record showed admission date on 11/7/2023 with diagnoses not limited to Interstitial pulmonary disease, Unspecified asthma, Chronic obstructive pulmonary disease, Anemia, Essential (primary) hypertension. MDS (Minimum Data Set) dated 11/6/2024 showed R28's cognition was moderately impaired. R84's admission record showed admission date on 7/31/2023 with diagnoses not limited to Unilateral primary osteoarthritis right hip, Anemia, Pain in right lower leg, Pain in left lower leg, Opioid dependence. MDS dated [DATE] showed R84's cognition was intact. R93's admission record showed admission date on 3/4/2024 with diagnoses not limited to Type 1 diabetes mellitus with hyperglycemia, Essential (primary) hypertension, Tobacco use, Atherosclerotic heart disease of native coronary artery without angina pectoris. MDS dated [DATE] showed R93's cognition was intact. On 2/4/25 at 10:56 AM Observed R28 lying in bed, on moderate high back rest, with oxygen therapy via nasal cannula at 2L/min, with lighter at bedside table and nightstand near the oxygen concentrator. Requested V8 (REGISTERED NURSE / RN) to R28's room and stated R28 is using oxygen continuously. V8 saw the lighter at R28's bedside. R28 said he used to smoke but not anymore. R28's Care plan documented in part: tobacco use: R28 is a smoker and desire to smoke. R28 will be assessed and monitored to fully manage compliance with facility rules. On 2/04/25 at 11:01 AM Observed R93 lying in bed, on moderate high back rest, alert and verbally responsive. Stated he is smoking 4x per day in the 3rd floor smoking patio / balcony. R93 stated he has been residing in the facility for almost a year in March. He said cigarettes are kept by facility staff, but he has a lighter in his pocket and showed it to the surveyor. On 2/4/25 at 11:05 AM Observed R84 lying in bed in moderate high back rest, alert and oriented x 3, verbally responsive. Stated he is a smoker and smoking at least 3x daily in the 3rd floor balcony / patio. R84 said during smoking breaks staff is always present to supervise them. He stated he is keeping his cigarette and lighter and showed to the surveyor. Observed 1 stick of cigarette and lighter in R84's possession. On 2/5/25 at 11:47 AM V6 (Social Service Director / SSD) stated has been working in the facility for 15 years and transitioned as SSD for a year. She said smoking assessment is done upon admission, quarterly and as needed. V6 said smoking materials such as cigarettes and lighters are kept by facility staff every after smoking break for safety. V6 said resident should not have cigarette or lighter in their possession as they can potentially smoke in the building and could catch fire. She said 145939 Page 7 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0689 facility have oxygen in the building, so it is not safe for the residents to have lighter in their possession. Level of Harm - Minimal harm or potential for actual harm On 2/5/25 At 1:01pm V2 (DIRECTOR OF NURSING / DON) stated lighter should be kept by facility at all times. She said if resident has lighter in their possession it may start a fire in the building especially for those resident using oxygen. Residents Affected - Few R28's smoking safety policy contract dated 5/16/24 showed in part: immediately turn over all smoking materials (cigarettes, lighter) to a staff person. R28's smoking and safety assessment dated [DATE] showed in part: R28 is no longer an active smoker due to the need of continuous oxygen. R84's smoking safety policy contract dated 5/16/24 showed in part: immediately turn over all smoking materials (cigarettes, lighter) to a staff person. R84's smoking and safety assessment dated [DATE] showed in part: Supervision, designated smoking location, and smoking times are determined by facility policy. R84 is an active smoker. R84 has been deemed reeducated on the facility smoking program. Care plan documented in part: TOBACCO USE: R84 is a smoker and desire to smoke. R84 will be assessed and monitored to fully manage compliance with facility rules. R93's smoking and safety assessment dated [DATE] showed in part: Supervision, designated smoking location, and smoking times are determined by facility policy. R93 is an active safe smoker. R93 has been deemed reeducated on the facility smoking program. R93's smoking safety policy contract dated 5/16/24 showed in part: immediately turn over all smoking materials (cigarettes, lighter) to a staff person. Care plan documented in part: TOBACCO USE: R93 is a smoker and desire to smoke. R93 will be assessed and monitored to fully manage compliance with facility rules. Facility's oxygen care and storage policy dated 12/2017 documented in part: Spark producing devices shall be prohibited in areas where oxygen is in use. Facility's smoking safety policy (undated) documented in part: To provide a safe and healthy living environment with respect for health and well-being needs of each resident, staff member and visitor. The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in his / her possession for health, safety and security reasons. 145939 Page 8 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oxygen use and no smoking signage was posted on a resident's (R213) door who's on continuous oxygen, failed to date humidifier bottle for oxygen concentrator and nebulizer mask for 1 (R71) resident, and failed to follow physician order for oxygen liter flow and provide humidification for continuous use of oxygen for 1 (R28) resident out of 3 residents reviewed for respiratory care in a final sample of 23. Residents Affected - Few Findings Include: On 2/04/25 at 11:24 AM, R213's sleeping in bed observed on oxygen at 3 liters per minutes (LPM) via nasal cannula. Surveyor did not observe oxygen in use and no smoking signage posted on R213's door or over R213's bed. On 2/05/25 at 11:22 AM, R213's lying in bed alert and able to verbalize needs. R213 was using oxygen via nasal cannula set to 3 LPM. R213 stated that [R213] has heart failure and [R213's] oxygen saturation goes down at times. There was no oxygen in use and no smoking signage posted on R213's door or over R213's bed. On 2/05/25 at 12:46 PM, interviewed V2 (Director of Nursing) and stated that there should be an order for the oxygen use in the resident's chart. The nurses should follow the physician's order when administering oxygen to residents. The oxygen flow rate is ordered by the physician. V2 stated that oxygen tubing and the water canister for the oxygen humidifier should be changed once a week, and both should be labeled with the date when they are changed. The oxygen concentrators should have the water humidifier to keep the residents' nose from drying. V2 further stated that residents on oxygen use should have an oxygen signage posted on the door that says oxygen in use and no smoking and there should be no one smoking around the area with oxygen. R213's clinical records show an initial admission date of 1/31/25 with included diagnoses but not limited to Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. R213's Minimum Data Set, dated [DATE] shows R213 is moderately impaired in cognition. R213's physician orders read in part: May use Oxygen at (3) L/min continuous every shift (ordered 2/01/25). The facility's Oxygen Care and Storage policy dated 12/17 documented in part: No Smoking signs must be clearly visible in areas where oxygen is stored or in use. The facility's Oxygen Administration policy dated 3/20 documented in part: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Place an Oxygen in Use sign on the outside of the room entrance door. R28's admission record showed admission date on 11/7/2023 with diagnoses not limited to Interstitial pulmonary disease, Unspecified asthma, Chronic obstructive pulmonary disease, Anemia, Essential (primary) hypertension. On 2/4/25 at 10:56 AM surveyor observed R28 lying in bed, on moderate high back rest, with oxygen via nasal cannula at 2L/min. No humidifier found while resident is using continuous oxygen. Requested V8 (Registered Nurse / RN) to R28's room and stated oxygen setting is at 2L/min continuously. V8 145939 Page 9 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said R28 does not have humidification for continuous use of oxygen. R28 said he is using oxygen continuously and at times his nose is so dry. R28's order summary report dated 2/5/25 with active order not limited to: Oxygen per Nasal Cannula at (3) L/min continuous every shift related to Interstitial pulmonary disease; Chronic obstructive pulmonary disease. Care plan documented in part: R28 is at risk for altered respiratory status / difficulty in breathing related to diagnosis of Interstitial pulmonary disease; Asthma. Give oxygen therapy as ordered. MDS (Minimum Data Set) dated 11/6/2024 showed R28's cognition was moderately impaired. Facility's oxygen care and storage policy dated 12/2017 documented in part: Oxygen therapy is administered to the resident only upon the written order of a licensed physician. Oxygen is to be administered at the prescribed rate prescribed by the physician. R71's electronic medical record (EMR) revealed R71 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Chronic obstructive pulmonary disease (COPD), unspecified diastolic congestive heart failure, asthma, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, dependence on supplemental oxygen, and hypertensive heart disease with heart failure. On 2/4/25 at 11:50 AM, R71 received in bed, on oxygen, the humidifier bottle, and the nebulizer mask by R71's bed side has no date. At 1:10 PM V13 (Licensed Practical Nurse/LPN) stated that V13 has been in the facility for seven years, and that R71's humidifier bottle and Nebulizer mask are not dated. V13 stated that R71 is on continuous oxygen at 3 liter/minute for shortness of breath (SOB), and R71's humidifier bottle and nebulizer mask should be changed and dated weekly to prevent risk of infection. On 2/5/25 at 2:26 PM V2 (Director of Nursing/DON) stated that it is V2's expectation that nurses will change and date humidifier bottle for oxygen concentration and nebulizer mask weekly on Thursday and as needed. V2 stated that, when the humidifier bottle and nebulizer mask are not dated, the staff will not know when the tubing was changed and that can increase the risk of infection for the resident. Documents Reviewed: R71's Minimum Data Set (MDS) dated [DATE] shows R71 is cognitively impaired. R71's Physician Order Sheet (POS) with active orders as of 2/5/25 shows orders: Oxygen per nasal cannula at 3 liter/minute continuous every shift for SOB. Ipratropium-Albuterol 3ml inhale orally every 6 hours as needed for SOB. Change and date oxygen tubing humidification bottle every Sunday and change nebulizer tubing weekly every Sunday. Facility Policy titled, Oxygen Care and Storage dated 12/2017 documents in part: Oxygen tubing will be changed weekly and dated. Facility Policy titled, 'Nebulizer Administration' dated 3/2020 documents in part: Masks and T-Piece mouth apparatus are to be changed weekly and dated at the time they are changed. 145939 Page 10 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess the risk versus benefits of using a bed rail and review them with the resident prior use, and failed to implement person-centered comprehensive care plan addressing the use of the bed rail. These failures have the potential to affect 1 (R213) out of 4 residents reviewed for bed rails in a final sample of 23. Findings Include: On two separate occasions on 2/04/25 at 11:24 AM and on 2/05/25 at 11:22 AM, R213 was observed resting in bed and noted with one full bed rail up on the right side of R213's bed. On 2/05/25 at 1:50 PM, interviewed V14 (Restorative Licensed Practical Nurse) and stated that restorative does the residents' bed rail assessments, and they need to be completed before using the bed rail. V14 stated that the purpose of the bed rail assessment is to determine the need for use of bed rails prior to use. V14 stated [V14] will first explain to the resident or representative what rails are used for and the complications. V14 stated that the use of the bed rails should be addressed in the care plan and needs to be updated quarterly, annually, and with any changes. V14 stated that all interventions related to the use of the bed rail should be in the resident's care plan for the staff to know what to do for the resident. R213's clinical records show an initial admission date of 1/31/25 with included diagnoses but not limited to Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. R213's Minimum Data Set, dated [DATE] shows R213 is moderately impaired in cognition. R213's Assist Rail Screening was signed and completed on 2/05/25 and revealed recommended side rail use for R213 was 2 half rails. R213's comprehensive care plan does not address the use of the bed rail to indicate which medical need would be met through the use of bed rails and there is no identification of interventions to address any potential complication with the use of bed rail. The facility's Proper Use of Side Rails policy dated 10/20 documented in part: Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. The use of side rails as an assistive device will be addressed in the resident care plan. 145939 Page 11 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to: 1-Perform proper hand hygiene when passing food tray, after handling soiled dishes, and before handling clean dishes. 2- Properly label perishable items inside the walk-in fridge 3- Prevent personal food items inside the walk-in fridge. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen. Findings include: On 2/4/25 at 9:50 AM, during initial round with V9 (Director of Dietary), surveyor observed the prepared apple sauce dated 1/29/25, concord grape jelly without a discard date, and a personal bottle of energy drink and water inside the walk-in fridge. V9 stated that the apple sauce is over six days and it is expired, and every item should have an in and out date, and serving residents with an expired food without proper storage could make resident sick with food borne illness. V9 stated that personal/staff food or drink should not be inside the walk-in fridge. V9 stated there is only one resident who receives nothing by mouth (NPO). On 2/4/25 at 9:53 AM, V10 (Dietary Aide) stated that V10 kept V10's personal bottle of energy drink and a bottle of water inside the walk-in fridge. V10 stated that keeping personal items in the fridge could cause cross contamination. On 2/5/25 at 11:35 AM, V9 stated it is V9's expectation that staff will perform proper hand hygiene in dish room when moving from a dirty area to a clean area to prevent cross contamination. On 2/4/25 at 12:47 PM, surveyor observed V12 (Certified Nursing Assistant/CNA) passing lunch tray to residents without performing hand hygiene after knocking at the door to pick another lunch tray from the tray cart. V12 stated that V12 should have sanitized V12's hand in between each resident to prevent cross contamination. On 2/5/25 at 11:00 AM, observed V10 (Dietary Aide) and V16 (Dietary Aide) working in the dish room. V10 and V16 stated that whoever is on the clean side should be wearing gloves. Observed V16 was breaking down soiled resident trays scraping food debris from the trays into the garbage. At 11:10 AM, observed V16 moved to the clean side of the dish machine and pull out the rack containing cleaned trays from the dish machine without hand hygiene and gloves. V16 stated that V16 should have washed V16's hand and wear new gloves before touching clean trays to prevent cross contamination. At 11:23 AM observed V10 returning rack to the soiled area with sanitized trays and placed the same sanitized trays on an open cart to air-dry. V10 stated that V10 should not have taken the sanitized trays to the dirty area and back to the clean side. V10 returned the sanitized trays for a rewash. On 2/5/25 at 2:26 PM, V3 (Administrator in Training) stated it is V3's expectation that staff will perform proper hand hygiene by using the hand sanitizer in between residents when passing food tray 145939 Page 12 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0812 to prevent cross contamination. Level of Harm - Minimal harm or potential for actual harm Documents Reviewed: Diet type report as of 2/4/25 shows one resident who receives nothing by mouth (NPO). Residents Affected - Many Facility's policy titled Dish Room Safe Food Handling revision dated 2017 documents in part: If there is only one person working in the dish room, the person will remove their gloves, wash their hands, and put on fresh gloves whenever they cross over to the clean side of the dishwashing machine to unload the sanitized dishes and utensils. Facility's policy titled Hand Washing/Hand Hygiene dated 01/2014 documents in part: The facility considers hand hygiene the primary means to prevent the spread of infection. Facility's policy titled Refrigerated Food dated 2017 documents in part: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. The discard/use by date will be a maximum of six days after preparation. Facility's policy titled, Labeling and Dating Foods dated 2021 documents in part: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. 145939 Page 13 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to (1) dispose of kitchen garbage properly in a contained dumpster, (2) failed to keep the dumpster area clean free of debris, the garbage area was not maintained in a sanitary condition to prevent harborage and feeding of pest. These failures could affect all 111 residents that reside in the facility. Residents Affected - Many Findings Include: On 2/5/25 at 9:16 AM, During the initial facility tour, with V20 (Director of Maintenance) and V19 (Assistant Maintenance) observed the outside dumpster area where kitchen garbage is disposed with the large dumpsters uncovered with lids. All around the dumpsters were food garbage, papers, and foul odors. V19 stated that the dumpster is open, but it should be covered. V20 stated that the uncovered plastic bags in the dumpster are from the kitchen, and the housekeeping. V20 stated that when the lids to the two dumpsters are not properly covered, it could invite pest, racoons to the facility. V20 stated that V20 will call the garbage pick-up company to pick up the dumpsters. Facility policy titled Waste Disposal dated 01/2014 documents in part: Regulated waste shall be handled and disposed of in a safe and appropriate manner. The area surrounding the dumpster is maintained clutter free, the dumpsters lids are closed after disposal of the waste. 145939 Page 14 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility [A] failed to ensure shared equipment were cleaned and decontaminated between each use for 4 [R61, R68, R72, R263] and [B] failed to follow their infection control procedures to post Enhanced Barrier Precautions (EBP) signage outside 1 [R39's room] resident with active right subclavian perma catheter for dialysis in a sample of 23 residents. Residents Affected - Some Findings Include: On 2/4/25 at 9:42AM, V8 obtained R61's blood pressure [103/69] with a manual blood pressure device placed on R61's bed linen, that was on top of the medication cart. After use, V8 then placed the manual blood pressure device back on top the medication cart and did not sanitize the blood pressure device. On 2/4/25 at 10:11 AM V8 obtained R72's blood pressure [130/73] with the same blood pressure device, sitting on the bed side, without sanitizing the device blood pressure. On 2/4/25 at 10:20 AM V8 obtained R263's blood pressure [123/71] used the manual blood pressure cuff sitting on R263 legs to obtain R62's blood pressure without sanitizing the device. On 2/4/25 at 10:38 AM, V8 obtained R68's blood pressure [145/103] used the manual blood pressure cuff, to obtain R68's blood pressure without sanitizing the device. On 2/4/25 at 11:00 AM, V8 stated, I forgot to sanitize the blood pressure cuff between each resident, and that could cause a spread of infection. On 2/6/25 at 2:44PM, V2 [Director of Nursing] stated, All resident's shared equipment such as blood pressure cuff must be sanitized between each resident to prevent the spread of infection. It could potentially cause an infectious outbreak. Policy documents in part: Resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected. R39's face sheet shows R39 is a [AGE] year-old male. R39's electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with diagnoses not limited to end stage renal disease (ESRD), dependence on renal dialysis, cardiac tamponade, malignant neoplasm of prostate, malignant neoplasm of colon, secondary malignant neoplasm of unspecified lung, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of bone, and tinea pedis. On 2/4/25 at 11:53 AM, R39 received up in chair in room with an active right subclavian Catheter with no EBP signage on R39's door. R39 stated that R39 goes out for dialysis three times a week, and R39 is not sure if the staff wear gown when staff inspect R39's catheter dressing. On 2/5/25 at 1:15 PM, V18 (Licensed Practical Nurse/LPN) stated that V18 has been in the facility for eight years. V18 stated that Enhanced Barrier Precautions (EBP) signage should be posted outside the door of any resident with wounds, feeding tube, Foley Catheter, Dialysis Perma catheter, central 145939 Page 15 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some line, and other isolation. V18 stated it is important to have EBP signage to ensure that staff are wearing the necessary Personal Protective Equipment (PPE) required before providing care for R39. On 2/5/25 at 2:26 PM, surveyor V2 (Director of Nursing) stated that there should be a EBP signage by the door of any resident with Foley Catheter, Dialysis Perma catheter, and wound to alert staff to know the type of PPE to wear before providing care to the resident. V2 stated that not having the signage by the door of resident with dialysis Perma catheter, is a potential for transmission of infection. On 2/5/25 at 2:35 PM, V4 (Infection Preventionist/LPN) stated that the EBP should be on the door of a dialysis resident (R39) so that staff will put on appropriate PPE like gown and gloves before providing care for R39 to prevent transmission of infection. Documents Reviewed: R39's Minimum Data Set (MDS) dated [DATE] shows R39 is cognitively intact. R39's Physician Order Sheet (POS) with active orders as of 2/5/25 shows orders: EBP due to dialysis, monitor for signs/symptoms of infection-right chest permcath every shift, and may go to dialysis 3x/week at Fresenius kidney care. R39's Care plan dated 12/18/24 documents in part: R39 is receiving hemodialysis treatments related to ESRD, potential risk for complications. R39 has a dialysis shunt and requires advanced barrier precautions. Monitor right chest permcath site for any sign/symptoms of infection. The facility policy titled Enhanced Barrier Precautions (EBP) dated 5/2022 documents read in part: Post clear signage on the door or wall outside of the resident room indicating the type of precautions, and required Personal Protective Equipment (PPE) (e.g., gown and gloves) A copy of EBP signage documents in part: Providers and staff must wear gloves and a gown for high-contact resident care activities; central line, any skin opening requiring a dressing. 145939 Page 16 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 assess eligibility and offer pneumococcal vaccine to three (R39, R48, R72) of five residents reviewed for pneumococcal immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the Pneumococcal vaccinations in a sample of 23. Residents Affected - Few The findings include: 1. R39's admission record showed admission date on 5/19/2020 with diagnoses not limited to End stage renal disease, Malignant neoplasm of prostate, Cardiac tamponade, Hypothyroidism, Secondary malignant neoplasm of bone, Malignant neoplasm of colon, Secondary malignant neoplasm of liver and intrahepatic bile duct, Secondary malignant neoplasm of unspecified lung, Essential (primary) hypertension, Dependence on renal dialysis. R39's MDS (Minimum Data Set, dated [DATE] showed cognition was intact. MDS showed Pneumococcal vaccine was not up to date. Reviewed R39's immunization record, no documentation found for pneumococcal vaccine. R39's Covid-19 vaccine consent form dated 11/13/24 showed I do not give consent, however no documentation found for screening questions to determine eligibility of the vaccine. Pneumococcal vaccination informed consent form did not reflect / show that R39 or representative refused vaccine. 2. R48's admission record showed admission date on 9/5/2024 with diagnoses not limited to Cerebral infarction, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic neuropathy, acquired absence of right leg above knee, Acquired absence of left leg above knee, Peripheral vascular disease, Essential (primary) hypertension, Heart failure, Chronic kidney disease, Chronic embolism and thrombosis of unspecified deep veins of lower extremity, Hypothyroidism. R48's MDS dated [DATE] showed cognition was moderately intact. MDS showed Pneumococcal vaccine was not up to date. R48's order summary report dated 2/6/25 with active order not limited to May have pneumococcal vaccine unless contraindicated. Reviewed R48's immunization record, no documentation found for pneumococcal vaccine. R48's Pneumococcal vaccine consent form dated 2/6/25 did not reflect consent was obtained, no documentation found that R48 or representative refused vaccine. No documentation found for screening questions to determine eligibility of the vaccine. 3. 145939 Page 17 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R72's admission record showed initial admission date on 8/12/2022 with diagnoses not limited to, Hypertensive heart and chronic kidney disease without heart failure, Unspecified chronic bronchitis, Hyperlipidemia, Bilateral primary osteoarthritis of knee, Peripheral vascular disease, Chronic kidney disease stage 3a. R72's MDS dated [DATE] showed cognition was intact. MDS showed Pneumococcal vaccine was not up to date. Reviewed R72's immunization record, no documentation found for pneumococcal vaccine. R72's order summary report dated 2/6/25 with active order not limited to May have pneumococcal vaccine unless contraindicated. R72's Pneumococcal vaccine consent form dated 8/27/24 showed do not give consent however informed consent form did not reflect consent was obtained, no documentation found that R72 or representative refused vaccine. No documentation found for screening questions to determine eligibility of the vaccine. On 2/6/25 At 2:06 PM V4 (IP / Infection Preventionist, LPN / Licensed Practical Nurse) stated pneumococcal vaccine should be offered to all residents in the facility according to CDC (Center for Disease Control) guidelines. Pneumonia vaccine could prevent severe complications incase resident contracted the disease (pneumonia). V4 said screening or assessment should be done to determine if resident is appropriate or eligible to receive the vaccine. She said physician order is needed to give the vaccine. V4 said screening questions are important to determine if vaccine is contraindicated due to resident has an allergic reaction or medical contraindication to receive the vaccine. She said informed consent should be obtained from resident or responsible party prior to immunization. V4 said consent, screening / assessment should be documented in resident's record. Facility's pneumococcal vaccine policy dated 3/2014 documented in part: All residents will be offered the pneumococcal vaccine to aid in preventing pneumococcal infections (Pneumonia). Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and when indicated, will be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessment of pneumococcal vaccination status will be conducted within 14 days of the resident's admission if not conducted prior to admission. Residents / representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 145939 Page 18 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow facility's policy and procedure, the facility failed to assess eligibility and offer covid-19 vaccine to three (R39, R48, R72) of five residents reviewed for covid-19 immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the covid 19 vaccinations in a sample of 23. The findings include: 1. R39's admission record showed admission date on 5/19/2020 with diagnoses not limited to End stage renal disease, Malignant neoplasm of prostate, Cardiac tamponade, Hypothyroidism, Secondary malignant neoplasm of bone, Malignant neoplasm of colon, Secondary malignant neoplasm of liver and intrahepatic bile duct, Secondary malignant neoplasm of unspecified lung, Essential (primary) hypertension, Dependence on renal dialysis. MDS (Minimum Data Set, dated [DATE] showed R39's cognition was intact. MDS showed R39's covid vaccination was not up to date. Reviewed R39's immunization record, no documentation found for Covid 19. R39's Covid-19 vaccine consent form dated 11/13/24 showed I do not give consent, however no documentation found for screening questions to determine eligibility of the vaccine. 2. R48's admission record showed admission date on 9/5/2024 with diagnoses not limited to Cerebral infarction, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic neuropathy, acquired absence of right leg above knee, Acquired absence of left leg above knee, Peripheral vascular disease, Essential (primary) hypertension, Heart failure, Chronic kidney disease, Chronic embolism and thrombosis of unspecified deep veins of lower extremity, Hypothyroidism, R48's MDS dated [DATE] showed cognition was moderately intact. MDS showed R48's covid vaccination was not up to date. Reviewed R48's immunization record, no documentation found for Covid 19. R39's Covid-19 vaccine consent form dated 2/6/25 did not reflect consent was obtained, no documentation found for consent. No documentation found for screening questions to determine eligibility of the vaccine. 3. R72's admission record showed initial admission date on 8/12/2022 with diagnoses not limited to, Hypertensive heart and chronic kidney disease without heart failure, Unspecified chronic bronchitis, 145939 Page 19 of 20 145939 02/07/2025 Pavilion of South Shore 7750 South Shore Drive Chicago, IL 60649

F 0887 Hyperlipidemia, Bilateral primary osteoarthritis of knee, Peripheral vascular disease, Chronic kidney disease stage 3a. Level of Harm - Minimal harm or potential for actual harm R72's MDS dated [DATE] showed cognition was intact. MDS showed COVID-19 vaccine was not up to date. Residents Affected - Few Reviewed R72's immunization record, no documentation found for COVID-19 vaccine. R72's COVID-19 vaccine consent form dated 7/29/24 showed no consent obtained or documented. No documentation found for screening questions to determine eligibility of the vaccine. On 2/6/25 At 2:06 PM V4 (IP / Infection Preventionist, LPN / Licensed Practical Nurse) stated COVID-19 vaccine should be offered to all residents in the facility according to CDC (Center for Disease Control) guidelines. She said COVID-19 vaccine could prevent severe complications incase resident contracted the disease. V4 said screening or assessment should be done to determine if resident is appropriate or eligible to receive the vaccine. V4 said screening questions are important to determine if vaccine is contraindicated due to resident has an allergic reaction or medical contraindication to receive the vaccine. She said informed consent should be obtained from resident or responsible party prior to immunization. V4 said consent, screening / assessment should be documented in resident's record. Facility's COVID-19 policy dated 4/2024 documented in part: Vaccination of covid 2023-2024 are a key component of the core infection control principals. Facility must offer COVID-19 vaccinations as recommended by CDC. Screening individuals prior to offering the vaccination for prior immunization., medical precautions and contraindications will be completed for determining whether they are appropriate candidates for vaccination at any given time. 145939 Page 20 of 20