Health inspection·February 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report allegations of misappropriation of property for one (R1) out of three residents reviewed for misappropriation of resident property in a total sample of three residents. Findings include: On 02/22/2025, at 12:07 PM, V4 (Social Services Director) states she recalls having a conversation with V9 (R1's Family Member) and educating V9 about filling out an inventory list whenever new items or valuables are brought into the facility for R1 in case something comes up missing. V4 states V9 informed her that R1 had a diamond ring and bracelet on when R1 was admitted to the facility. V4 states she informed V9 that these items were not inventoried but V9 was insistent that R1 had these items. V4 states she searched for R1s' inventory list but could not find one and states the facility does not have an inventory list of R1s' diamond ring or bracelet. V4 states an inventory list should be completed by staff upon admission for all residents but she does not have an inventory list for R1. V4 states she does not remember seeing R1 with a ring or bracelet. V4 states she informed V3 (Assistant Administrator) about the allegations and V3 reimbursed V9 for the ring and bracelet items. V4 states this incident occurred approximately in late 2023 or early 2024. On 02/22/2025, at 1:07 PM, V3 (Assistant Administrator) states he is aware of the allegations of R1s' missing ring and bracelet. V3 states this incident happened late in 2023 and was handled by V8 (Former Administrator). V3 states he remembers V8 having a meeting with V9 (R1s' family member) and V8 paid V9 approximately 200 dollars to replace R1s' missing items. V3 states R1s' missing items should have been reported and he will gather as much information that he can find that is related to the allegations. V3 states he is aware that the facility should retain documentation of resident files for a time period even after they are discharged from the facility. Facility reported incident for misappropriation of property for R1 was requested from V3 (Assistant Administrator) on 02/22/2025 at 1:07 PM. On 02/22/2025, at 2:20 PM, V3 provides surveyor with a form titled Petty Cash Reconciliation Form and states R1s' initials are located at the bottoms of the list and R1 was reimbursed 180 dollars for her missing items. V3 also provides surveyor a document dated 12/17/2023, titled Final investigation- Missing bracelet for R1 and a document titled Fax Initial Reportable Accident/Incident to IDPH (Illinois Department of Public Health) Regional Office. V3 states this was the only documentation that he could find regarding R1s' misappropriation of property allegations. Surveyor makes V3 aware that there is no documentation to show that the initial and final reports were faxed/submitted to the state agency. V3 observes the final report and is made aware that there is no fax confirmation and no (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 4 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 02/24/2025 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)