Pavilion Of Logan Square, The

In the surveyor’s words

From the most serious findings on record at Pavilion Of Logan Square, The, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 19, 2024

  Based on interview and record review, the facility failed to: a. implement care plan interventions for one resident (R2) and b. failed to ensure staff follow their job description and Driver Safety Rules for two residents (R3, R6) for three of three residents reviewed for falls in the sample of six. These failures resulted in R2 sustaining facial lacerations and R3 sustaining neck fractures. Findings include: a.11/13/2024, at 11:02 AM, V5 (Certified Nursing Assistant) via telephone, said I helped V7 (Certified Nursing Assistant) transfer R2 from shower chair to bed using a gait belt. V7 said I left the room. 11/13/2024, at 11:34 AM, V7 (Certified Nursing Assistant) said I gave R2 his shower the day he fell out of bed. […]

• Actual harm, isolatedF689Aug 12, 2024

  Based on observations, interviews, and record review, the facility failed to a.) implement fall precaution interventions for two (R1, R3) residents, b.) provide adequate supervision and monitoring to prevent falls for two (R1, R2) residents, and c.) provide supervision and monitoring for four (R4, R5, R6, R7) residents during the designated smoking time to ensure residents practice safe smoking in the designated area. Theses failures resulted in R1 falling while in the facility on 07/06/2024 and sustaining a facial laceration. R1 experienced a subsequent fall while in the facility on 07/29/2024 and sustained a head contusion. R2 fell on [DATE] while in the facility and sustained an iliac crest fracture of the pelvis. […]

• Actual harm, isolatedF686Dec 18, 2023

  Based on observation, interview and record review the facility failed to provide timely incontinence care to prevent MASD (Moisture Associated Skin Damage), failed to document skin integrity impairment, failed to obtain timely treatment orders, and failed to offload wounds for one of three residents (R2) reviewed for pressure ulcers. These failures resulted in R2 incurring (facility acquired) stage 4 sacrum pressure ulcer (with bone exposed), osteomyelitis secondary to infection, fractured S5 vertebra - in the setting of osteomyelitis, pain rated 5/10, and severe sepsis. The facility also failed to follow physician orders, failed to ensure that dressings were changed daily, failed to prevent MASD, and failed to offload wounds for R1. […]

• Actual harm, isolatedF689Dec 18, 2023

  Based on observation, interview and record review the facility failed to ensure (R3's) functional assessment was accurate, failed to ensure staff use proper and/or appropriate transfer techniques, failed to implement and/or revise fall care plan interventions, failed to provide supervision, and failed to obtain a timely x-ray for one of three residents (R3) reviewed for falls/IOUO (Injuries of Unknown Origin). These failures resulted in R3 sustaining acute fractures of the left lateral 7th through 9th ribs (identified 12/2/23) and pain rated 3/10. The facility also failed to implement the falls management policy, failed to document (R4's) fall, failed to notify (R4's) family/physician immediately and failed to conduct daily skin assessments. […]

• Actual harm, isolatedF600Jun 27, 2023

  Based upon observation, interview and record review the facility failed to provide nursing care to (R6), failed to follow the abuse prevention program and failed to ensure that one of six residents (R3) in the sample remained free from abuse. R3 sustained (6/18/23) dislocated shoulder and affirmed that staff caused the injury. Findings include: On (6/20/23) IDPH (Illinois Department of Public Health) received allegations that on 6/18/23, R3's shoulder was dislocated by an unknown staff. R3's diagnoses include dementia without behavioral disturbance. R3's (5/8/23) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R3's (5/8/23) functional assessment affirms (1 person) physical assist is required for bed mobility/locomotion. […]