Inspection Reports for
Buckingham Pavilion Nursing and Rehabilitation
2625 W Touhy Ave, Chicago, IL 60645, United States, IL, 60645
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
300% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 9
Date: Nov 15, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home care and resident services.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during care, improper placement of call lights, failure to protect resident medication record confidentiality, inadequate PASRR screening for residents with mental health diagnoses, failure to perform routine wellbeing checks, unlabeled enteral feeding bottles, lack of dental care for a resident, restricted access to electronic health records for surveyors, and failure to provide and document influenza and pneumococcal vaccinations and education.
Deficiencies (9)
F 0550: Facility failed to maintain resident privacy during bedside care by not using privacy curtains or closing doors, exposing a resident during care.
F 0558: Facility failed to ensure call lights were within reach for a resident, increasing risk of falls and delayed care.
F 0583: Facility failed to protect confidentiality of residents' medication administration records by leaving computer screens unlocked and visible.
F 0644: Facility failed to coordinate PASRR assessments and referrals for residents with serious mental disorders, affecting four residents.
F 0677: Facility failed to perform routine wellbeing checks every two hours for a dependent resident, resulting in prolonged soiling and risk of wound worsening.
F 0693: Facility failed to label enteral feeding and water bottles with resident information, risking administration errors and harm.
F 0790: Facility failed to provide dental services for a resident with difficulty chewing due to lack of dentures.
F 0842: Facility failed to provide timely and complete access to residents' electronic health records to surveyors, impeding thorough review.
F 0883: Facility failed to provide and document influenza and pneumococcal vaccinations and resident education for three residents.
Report Facts
Residents reviewed: 23
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 102
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V15 | Certified Nursing Assistant | Named in privacy deficiency for failing to use privacy curtain during bedside care |
| V1 | Administrator | Provided statements on privacy and EHR access issues |
| V3 | Wound Coordinator/Acting Director of Nursing/Registered Nurse | Provided statements on privacy, call light policy, wellbeing checks, feeding tube labeling, dental care, and vaccination education |
| V5 | Registered Nurse | Observed call light placement and assisted resident |
| V6 | Licensed Practical Nurse | Observed unlabeled enteral feeding bottles |
| V8 | Admissions Director | Provided statements on PASRR screening process |
| V9 | Registered Nurse | Observed medication administration with unlocked computer screens |
| V13 | Registered Nurse | Provided statement on resident dental status |
| V14 | Social Service Director | Provided statements on PASRR coordination |
| V4 | Quality Assurance/Infection Preventionist | Provided statements on vaccination documentation |
| V7 | Certified Nursing Assistant | Observed neglect in repositioning resident |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 8, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements related to resident care, medication management, nutrition, respiratory care, medication storage, food preparation, and resident dignity.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care and transport, unclear medication orders, inadequate nutritional assessments and interventions, improper respiratory equipment storage, unlabeled insulin vials, failure to follow standardized recipes for pureed diets, failure to update care plans to reflect diet orders, and improper food handling and storage practices.
Deficiencies (9)
F 0550: Facility failed to honor residents' rights to dignity and proper care during transport and feeding assistance, including pulling a resident backwards in a shower chair and feeding a resident while standing rather than at eye level.
F 0684: Facility failed to clarify a physician's medication order for Olanzapine for one resident, resulting in confusion about the correct dosage.
F 0692: Facility failed to complete nutritional assessments for residents with significant changes in nutritional status, affecting one resident with severe weight loss and malnutrition.
F 0695: Facility failed to ensure respiratory care equipment was stored properly to prevent contamination for three residents receiving respiratory care.
F 0761: Facility failed to label opened insulin vials and pens with open and discontinue dates on one medication cart, risking medication errors for two residents.
F 0803: Facility failed to follow standardized recipes during pureed food preparation, resulting in inconsistent food texture and potential nutritional inadequacy for six residents.
F 0803 (continued): Facility job descriptions and policies require use of standardized recipes and dietitian review of menus to ensure nutritional adequacy.
F 0805: Facility failed to follow physician's orders for a pureed diet and did not update the resident's care plan accordingly, resulting in a resident receiving inappropriate food.
F 0812: Facility failed to use utensils or gloves when handling resident food, improperly stored food items, failed to perform hand hygiene between handling dirty and clean kitchenware, and failed to air dry kitchen equipment before use, risking cross contamination and foodborne illness.
Report Facts
Residents reviewed for dignity: 18
Residents affected by dignity deficiency: 2
Residents reviewed for medications: 18
Residents affected by medication order deficiency: 1
Residents reviewed for nutrition and weight loss: 6
Residents affected by nutritional assessment deficiency: 1
Residents reviewed for respiratory care: 18
Residents affected by respiratory care equipment storage deficiency: 3
Medication carts reviewed: 6
Residents affected by insulin labeling deficiency: 2
Residents receiving pureed food: 85
Residents affected by pureed food preparation deficiency: 6
Residents affected by food handling deficiency: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 | Certified Nursing Assistant (CNA) | Named in dignity and transport deficiency for pulling resident backwards in shower chair |
| V2 | Director of Nursing | Provided statements on proper transport and respiratory equipment storage |
| V22 | Certified Nursing Assistant (CNA) | Named in dignity deficiency for feeding resident while standing |
| V29 | CNA Supervisor | Provided statements on feeding assistance dignity and food handling |
| V13 | Nurse | Named in medication order clarification deficiency |
| V30 | Neurologist and Movement Disorder Specialist | Named in medication order clarification deficiency |
| V17 | Registered Dietitian | Named in nutritional assessment and food preparation deficiencies |
| V24 | Certified Nursing Assistant (CNA) | Named in nutritional assessment deficiency for weighing resident |
| V25 | Certified Nursing Assistant (CNA) | Named in nutritional assessment deficiency for weighing resident |
| V5 | Registered Nurse | Named in respiratory equipment storage deficiency |
| V4 | Registered Nurse | Named in insulin labeling deficiency |
| V14 | Dietary Assistant/Cook | Named in pureed food preparation and food handling deficiencies |
| V10 | Food Service Director/Manager | Named in food storage and handling deficiencies |
| V11 | Dietary Assistant | Named in food handling and dishwashing deficiencies |
| V21 | Certified Nursing Assistant (CNA) | Named in food handling deficiency for bare hand contact with resident food |
| V1 | Administrator | Provided policy and resident diet order lists |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 2, 2023
Visit Reason
Routine inspection of Buckingham Pavilion nursing home to assess compliance with regulatory standards and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity, call light accessibility, gastrostomy tube feeding procedures, pressure ulcer prevention, respiratory care, pharmaceutical services, medication storage, food safety, infection control, and call system functionality. Deficiencies were generally of minimal harm and affected few to some residents.
Deficiencies (10)
F 0550: The facility failed to ensure one resident's urinary catheter drainage bag was covered with a privacy cover, affecting dignity.
F 0558: The facility failed to ensure a call light was within reach for one resident, compromising ability to summon help.
F 0658: The facility failed to check gastrostomy tube placement before connecting tube feeding for one resident, risking aspiration pneumonia.
F 0686: The facility failed to set a low air loss mattress according to resident's weight and mode, risking skin breakdown for one resident.
F 0695: The facility failed to ensure oxygen tubing and humidifier bottles were dated and changed timely for five residents, risking infection.
F 0755: The facility failed to maintain shift change accountability records for controlled substances, affecting 64 residents on two floors.
F 0761: The facility failed to discard expired eye drops and label opened multidose eye drops with open dates, affecting five residents.
F 0812: The facility failed to discard expired food in the walk-in cooler, risking foodborne illness for 86 residents.
F 0880: The facility failed to ensure staff used PPE and performed hand hygiene before entering and exiting a contact isolation room, risking infection transmission.
F 0919: The facility failed to have an operational call light for one resident, impairing ability to summon assistance.
Report Facts
Residents affected: 45
Residents affected: 64
Residents affected: 86
Missing nurse signatures: 15
Residents affected: 5
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Named in findings related to urinary catheter privacy cover, call light accountability, and controlled substances accountability |
| V9 | Certified Nurse Assistant | Named in findings related to call light accessibility and PPE use in isolation room |
| V6 | Certified Nurse Assistant | Named in gastrostomy tube feeding procedure deficiency |
| V3 | Minimum Data Set Coordinator / RN | Named in respiratory care deficiencies |
| V13 | Registered Nurse | Named in controlled substances accountability and medication storage deficiencies |
| V1 | Administrator | Named in multiple interviews regarding call light expectations, policies, and deficiencies |
| V2 | Acting Assistant Director of Nursing / Wound Care Coordinator | Named in gastrostomy tube feeding and medication storage deficiencies |
| V8 | Registered Nurse | Named in call light deficiency for resident R55 |
| V10 | Certified Nurse Assistant | Named in call light deficiency for resident R55 |
| V14 | Food Service Director | Named in expired food deficiency |
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