F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on interview and record review, the facility failed to notify a resident's family member in a timely
manner when a change in condition occurred. This failure affected 1 resident (R1) reviewed for changes in
condition.
Findings include:
On 4/13/2025 at 8:06 AM, R1's progress notes document in part, (R1) was noted with change in condition.
upon assessment SPO2 89% oxygen given at 2L, SPO2 94% on 2L Oxygen. HOB elevated 30dg. Hospice
notified.
On 4/13/2025 at 12:40 PM, R1's progress notes document in part that R1's family member (V11) was made
aware of the change in R1's condition at 11:15 PM.
On 5/5/2025 at 11:05 AM, V11 (R1's Family Member) stated that on 4/13/2025 at around 11:00 AM, V11
received a phone call from the facility around and informed V11 that R1 had taken a turn for the worst and
that R1 was in distress since 7:00 that morning. V11 recalled that V5 (Registered Nurse) had told V11 that
R1 was having abnormal vital signs, vomiting, and difficulty breathing. V11 explained that the nurse on night
shift that was responsible for R1's care had left without letting V11 know the change in condition. V11 stated
that it is the facility's policy to notify both the provider and the family when a change in condition is
identified.
On 5/6/2025 at 11:17 AM, V4 (Registered Nurse) affirmed that V4 was assigned to care for R1 on
4/13/2025 and noted a change in R1's condition around 7:00 AM. V4 described R1's change in condition
as, (R1) using accessory muscles to breathe (respiratory distress) and noted R1 to have hypoxia. V4
affirmed that when R1's change in condition was notified, V4 called hospice. V4 stated, (the facility staff)
notify the doctor immediately. The family can come last when everything is taken care of. The family is not
the priority, the patient is. V4 affirmed that V4 did not notify R1's family with the newly identified change in
condition. V4 stated, I endorsed calling (V11) to (V5- Registered Nurse), it was the end of my shift.
On 5/6/2025 at 12:45 PM, V5 (Registered Nurse) affirmed that V5 was assigned to care for R1 on the day
shift of 4/13/2025. V5 affirmed that V5 notified V11 of the change in condition at 11:15 PM. V5 stated that
V5 was reviewing (V4's) charting and noticed that (V4) had not called (V11) to report the change in
condition, so I (V5) did. V5 denied that calling V11 was endorsed to V5 by V4. V5 recalled, (V4) told me that
(V4) notified everyone that was supposed to be notified. V5 stated that the standard of practice is that
resident family members are notified promptly of any change in condition.
(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:
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
05/08/2025
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 5/7/2025 at 10:53 AM, V2 (Director of Nursing) affirmed that the facility policy is to notify the physician
and family whenever there is a change in condition as soon as a change is identified. V2 affirmed that V4
should have notified V11 promptly regarding R1's change in condition.
Facility policy titled, Change in a Resident's Condition or Status (4/2018) documents in part, Our facility
shall promptly notify the resident, his or her Physician, Nurse Practitioner, or Hospice Service as applicable,
and representative (sponsor) of changes in the resident's medical/mental condition and/or status (eg.
changes in level of care, billing/payments, resident rights, etc.) .
Event ID:
Facility ID:
145939
If continuation sheet
Page 2 of 2
