Health inspection·January 31, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the residents' rooms temperature are within the required comfortable and safe degrees Fahrenheit of between 71 to 81 degrees for 37 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) reviewed for comfort and safe environment. This failure affected (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) residing on the 2nd and 3rd floor and has the potential to affect all 86 residents residing in the facility. Findings include: On 01/23/23 at 12:58pm, V5 (Wound Care Nurse) stated that most of the residents have been complaining that their rooms are cold. V5 stated this was reported to V4 (Maintenance Director). V4 identified R13 as one of the residents actively complaining about the room temperature. V5 stated R13 has being complaining since sometime last week. V4 (Maintenance Director) who was present at the time stated in part that, but we are working on it. On 1/23/24 between 1:00pm and 2:00pm, on the 3rd floor during environmental observation with V4 (Maintenance Director) regarding temperatures in the resident rooms the following observations were made: On the 3rd floor of the facility Temperature in room [ROOM NUMBER] measured 59.9-degrees Fahrenheit room [ROOM NUMBER] measures 58.8-degrees Fahrenheit room [ROOM NUMBER] measures 66.9-degrees Fahrenheit room [ROOM NUMBER] measures 69.6-degrees Fahrenheit room [ROOM NUMBER] measures 69.4-degrees Fahrenheit-degrees Fahrenheit room [ROOM NUMBER] measures 68.4-degrees Fahrenheit Page 1 of 12 145415 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0584 1:13pm South hallway 68.2-degree Fahrenheit Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] 67.6-degrees Fahrenheit room [ROOM NUMBER] 63.8-degrees Fahrenheit Residents Affected - Some room [ROOM NUMBER] 65.1-degrees Fahrenheit At 1:40pm, both R2 noted in bed with four blankets covering, R2 and R3 who are roommates complained that the room is too cold, and nothing has been done to make it warm. room [ROOM NUMBER] 67.6-degrees Fahrenheit room [ROOM NUMBER] 63.8-degrees Fahrenheit room [ROOM NUMBER] 65.1-degrees Fahrenheit. At 2:20pm, R4 observed in the room, R4 complained stating that the room has been very cold lately. On 1/23/23 at 3:00pm, V4 was not putting any intervention in place to correct the low temperature until prompted by the surveyor. At 3:04pm, V4 could not present how the temperature is being monitored and what specific intervention is being made to correct the low temperatures readings. V2 (Nurse consultant/ Acting DON) who was present at this time then turned to V4 asking V4 to go now and start working on correcting this observation. V2 stated that this correction should have been started right away. On 1/24/24 at 9:59am, V1 (Administrator) stated that the temperature in the facility has not been fixed. V1 stated that V4 and V18 (Maintenance Supervisor) are in the outside hardware store to get some parts needed to fix the radiator (heating system). V1 stated in part that she is new to the building and from her understanding the 3rd floor is affected more than the other floors because there is no insulation in the ceiling. V1 stated as soon as the snow on the roof melts an outside company will come and check the roof to know what is needed to fix the problem. On 1/24/24 at 11:28am environment rounds made with V4 and V21 (Cooperate Maintenance Director). The surveyor asked V4 and V18 about what the root cause of the 3rd floor being mostly affected in the low temperature problem. V18 stated that some of the rooms are cold possibly because the staff opens the window during the care. We (referring to the facility) must call outside company to check on the roof maybe they can do better in correcting the problem. V18 stated the ceiling on the 3rd floor is not insulated and this can make the 3rd floor colder than the rest (referring to other floor of the facility). On the 3rd floor the following observation were made: South hallway 67.7-degree Fahrenheit West hallway 68.8 -degrees Fahrenheit room [ROOM NUMBER] 66.2-degrees Fahrenheit 145415 Page 2 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0584 room [ROOM NUMBER] 69.0-degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] 66.3-degrees Fahrenheit room [ROOM NUMBER] 68.5-degrees Fahrenheit Residents Affected - Some room [ROOM NUMBER] 69.6-degrees Fahrenheit room [ROOM NUMBER] 69.4-degrees Fahrenheit. These readings showed that some rooms are still having temperature that are below the required 71-degree Fahrenheit. On 1/24/24 at 1:15pm, V14 (Activity Director) confirmed the complaint, V14 stated in part that V4 was notified, and rounds were made on the floors. AC and windows were covered with plastic. V14 stated this mainly happens on the 3rd floor and all the residents were provided with extra blankets. The facility policy presented with revised date 1/16 titled Room Temperature Checks documented that the policy is to ensure proper room temperature is maintained at the acceptable range. Procedure listed includes that the room temperature must be maintained at the acceptable range of 71 to 81 degrees Fahrenheit. The room temperature that falls below the acceptable range of 71 degrees Fahrenheit listed steps to be taken includes but not limited to the staff will monitor the heating unit (winter) to ensure it is in proper working condition. And the retake of room temperatures will be reflected on the temperature log form. The facility policy on titled Director of Environment Services presented as the Job description for Maintenance Director documented in part that the primary purpose of the position is to plan, organize, implement, evaluate and maintenance departments in accordance with current, federal, state and local standards. guidelines, and regulations governing the facility and as directed by the administrator to assure that the facility is maintained in a safe and comfortable manner. 145415 Page 3 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

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 physician's orders and apply hand splint/brace for two of six residents (R2 and R4) with limited range of motion and failed to provide documentation related to application refusal of splint/brace. This failure affected R2 and R4 reviewed for assistive devices in the total of 86 residents. Findings include: On 01/23/23 1:41pm, R2 was noted lying in bed using the right hand to lift left hand trying to make sure it did not get caught up in the linen. R2 complained that the staff is not helping in applying the hand sling/brace. At 1:48pm, when this observation was brought to V12 CNA (Certified Nurse's Aide) assigned to R2 attention, V12 stated that I don't know about the hand splint, whether R2 is to wear it. V12 looked for the device in R2's bed side dresser drawer and V12 stated they are not in here (referring to the hand device splint/brace). V12 stated that the restorative devices are applied by the restorative aides. At 1:49pm V13 (Restorative Coordinator) who was on the floor at the time was called to R2's room and V13 stated that the R2's sling should be applied in the morning at least at 9:00am. That the staff for restorative called off, and there are not enough people to work. So, I have not been able to apply any splint for any of the residents. I'm working on getting this assessment done, I'm trying to catch up on the new admissions too. V13 stated in part that the sling helps R2 to move the hand easily. When asked whether this device is beneficial to R2, V13 stated definitely it is beneficial. R2's medical record listed diagnosis includes but not limited to Cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R2's electronic medical record showed documentation that showed a renewal for R2's restorative care with physician sign off dated 01/01/24 for R2 to have left hand and elbow extender orthosis on times one (1) hour as tolerated, nursing to monitor skin integrity, up as tolerated. R2's care plan was not updated to reflect new order dated 01/01/2024 timed 7:44pm. R2's plan of care with effective date 8/18/2023 on ADL (Activities of Daily Living) Active Range of Motion deficit documented under goals that R2 needs one staff stand by assistance for AROM (Active Range of Motion). Splint or brace assistance application program effective date 8/18/2023. Type of splint/brace to be used left hand, wrist resting splint, elbow extender to be on AM (Morning), Off PM (Evening) and during ADL care. R2's care plan for splint or brace assistance intervention with effective date 10/05/2023 documented interventions that includes that R2 will be assigned to a specific restorative/rehab aide to oversee the implementation of the daily program and treatment techniques. At 2:19pm, R4 observed sitting in bed in the room with V13 present at the time, R4's left hand appears weak and left thumb appears contracted. R4 observed using the right hand in moving and straightening the left hand, V13 stated R4 should have a splint to the left hand and wrist. V13 repeated 145415 Page 4 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0688 Level of Harm - Minimal harm or potential for actual harm there is no restorative aide to assist me (V13) in doing this. R4 then stated they (staff) have not been putting it on for a long time. R4's medical record listed Diagnosis includes but not limited to cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Residents Affected - Few R4's medical record showed standing order dated 08/17/2023 documented to apply splint as instructed, type of splint/brace. Wrist and thumb restriction splint. Location of application on left hand and wrist, thumb restriction splint, and left foot AFO. R4's plan of care documented focus on ADL: splint or brace assistance documented that R4 has observed to need assistance in performing some portion of splint /brace application program with effective date 08/03/2023. Goal includes but not limited to having it on in AM (morning) and off PM (afternoon) or during ADL care with effective date 11/06/2023. This plan of care was not followed. R4's care plan for splint or brace assistance intervention with effective date 08/03/2023 documented interventions that include R4 be assigned to a specific restorative/rehab aide to oversee the implementation of the daily program and treatment techniques. R2 and R4's electronic medical record reviewed did not show any documentation of R2 and R4's refusal to use of splint/brace. On 01/23/24 at 3:15pm, V2 (Nurse Consultant/ Acting DON) informed about the resident's not getting appropriate restorative care as needed and ordered and are not following the plan of care. V2 stated in part that she was not aware. V2 stated the facility just employees newly V13 (Restorative Coordinator) and she is now catching up with what to do. V2 stated in part that restorative orders must be followed as ordered, and plan of care updated. On 1/30/24 at 11:36am, V2 stated regarding splint/brace devices. I (V2) cannot defend why the splint/braces was not applied because V14 did not tell me (V2) about the splint/brace not been applied. I could have asked the other departmental heads staff member that are nurses to help. V2 stated some of the restorative orders were changed but the former Restorative nurse is no longer working here (referring to the facility). V13 is just starting to revise the restorative plan of care. V2 stated (V13) did not show up today. On 1/30/24 as at 4:00pm, the facility was unable to present any documentation that showed that R2 and R4 had refused care regarding the splint and braces or that R2 was refusing to use the extender orthosis device. The facility Restorative Nursing Assessment Policy dated 10/2023 presented, documented that the purpose of this policy includes to ensuring residents are maintained and/or restore to maximal level of function. Listed procedure includes residents assessed as possible candidate for restorative nursing will have a restorative assessment protocol implemented. 145415 Page 5 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

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. Based on observation, interview, and record review the facility failed to ensure that the residents environment remains free of accidental hazard by not leaving sharp items, disposable shaving razor and scissors that could harm the residents at the bedside. This failure affected R2 who had scissors on the bed and visible to the hallway and R12 who had disposable shaving razor on the bedside table. This has potential to affect all the residents residing on the 2nd and 3rd floor of the facility. Findings include: On 01/23/24 at 1:41pm, R2 noted in bed with four blankets covering, a pair of scissors was noted upon entering the room on R2's bed and visible to the hallway. R2's electronic medical record Face Sheet showed listed diagnosis information that includes but not limited to Cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Cerebral atherosclerosis, Major depressive disorder, Mild intermittent asthma, Dementia in other diseases classified elsewhere, unspecified severity with psychotic disturbances, Pain unspecified, Pain in right shoulder, Shortness of breath and Chronic obstructive disease. On 1/23/23 at 2:30pm, R12 was noted in R12s room and on the bedside table observed one used disposable shaving razor. R12 stated there was nowhere to keep it. When this was shown to V9 LPN (Licensed Practical Nurse) who identified self as the nurse assigned to R12 care. V9 stated that no sharp object should be kept at the bedside. V9 stated that the disposable razors are kept at the front in the supply room and the used ones should be disposed of after use for safety in the sharp's container because any of these residents can pick them up and injure themselves or others. R12's electronic medical record Face Sheet listed diagnoses includes paraplegia unspecified, peripheral vascular disease, major depressive disorder single episode severe with psychotic features, and schizoaffective disorder, bipolar type. -At 2:05pm V2 (Nurse Consultant / Acting DON) stated that the sharps are not supposed to be at the bedside. -At 2:10pm V3 (Interim DON) when asked what the facility policy on sharps that includes scissor storage and disposal. V3 stated let me check on that and I will let you know. On 01/24/24 at 11:10am, V3 stated that we are not supposed to have razors and scissors at the bedside or in the rooms because they are considered weapons and the residents are supposed to be kept safe. Facility policy on Disposal of Razors with revision date 08/22 documented that used razors/sharps are disposed of safely in conformance with applicable laws and safety regulations. Listed procedure includes but not limited to avoid risk of residents hurting themselves: used razors, are to be disposed in a sharp's container immediately after use. 145415 Page 6 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to provide enough staffing to meet the needed restorative services for two of six residents (R2 and R4) with limited ROM/range of motion and who are dependent on staff assistance in applying hand splint/brace devices. This failure affected R2 and R4 whose splint/braces are not applied, and this has the potential to affect all 74 residents identified as residents on restorative program and 22 residents on splint program. Findings include: On 01/23/24 between 1:00pm to 2:00pm, R2 and R4 were noted in their rooms with their splint/braces not in use as ordered by their physician. On 01/23/24 at 1:50pm V13 (Restorative Coordinator) who was on the floor at the time was called to R2's room and V13 stated that the R2's sling should be applied in the morning at least at 9:00am the staff for restorative called off, there are not enough people to work. So, I have not being able to apply any splint for any of the resident. I'm working on getting this assessment done I'm trying to catch up on the new admissions too. V13 stated in part that the sling helps R2 to move the hand easily. When asked whether this device is beneficial to R2. V13 stated definitely it is beneficial. V13 stated that none of the residents will be receiving any restorative care such as assistance in putting the sling/brace today because V13 has been instructed to complete assessments that are pending and the newly admitted residents. On 1/30/24 at 11:36am, V2 (Nurse Consultant / Acting Director of Nurse's) interviewed regarding splint/brace devices. V2 stated that I (V2) cannot defend why the splint/braces was not applied because V13 did not tell me (V2) about the splint/brace not being applied I (V2) could have had the other departmental heads staff member that are nurses to help. V2 in part stated that the physician order with the resident care plan must be followed. The facility Staffing Policy presented with revision date 10-2023 documented that the facility shall schedule nursing personnel so that the nursing needs of all the residents are met accordingly. The facility Restorative Nursing Assessment Policy dated 10/2023 presented documented that the purpose of this policy includes to ensuring residents are maintained and/or restore to maximal level of function. Listed procedure includes residents assessed as possible candidate for restorative nursing will have a restorative assessment protocol implemented. 145415 Page 7 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure that medication is stored in a locked cart when not in proximity of the nurse for two of three residents (R2 and R3) in the sample reviewed for medication administration. This failure affected R2 and R3 whose medications were left at the bedside without physician order to do so and has the potential to affect all 30 residents residing on the 3rd floor. Findings include: On 01/23/24 at 1:41pm, R2 noted in bed with four blankets covering, a pair of scissors noted upon entering the room on R2's bed and visible to the hallway. An open bottle of medication Methyl Salicylate Camphor (Menthol counter irritant) not labeled with name and directions noted on the overbed side table. R2 stated I use that for my leg pain. The medicine is from Philippines. During the same observation, R3 observed in bed with albuterol inhaler, artificial tears, fluticasone propionate, and deep-sea nasal spray noted on the bedside table visible to the hallway. R3 stated the nurse gave it to me (referring to self) and I (R3) use them. R3 stated that I (R3) can keep them with me (referring to bedside). When shown to V6 LPN (Licensed Practical Nurse), V6 stated that there should be no medication stored at bedside without physician order. I am not sure whether (R3) has an order to keep this medication at bedside because I don't work at this facility, I was sent from another facility to help because there was no nurse to work this morning. When asked whether these medications were administered this morning to R3. V6 stated I am not sure let me check. At 1:56pm, V6 searched the EMAR (Electronic Medication Administration Record), V6 stated that there was no physician order for R3 to have this medication at bedside and was unable to present any self-administration of medication assessment done to determine whether R3 can self-administer medication safely. V6 could not present any physician order for Methyl Salicylate Camphor (Menthol counter irritant) for R2. V6 stated the family might have brought the medication. V6 stated in part that this medication must still be ordered by the primary physician for R2 for administration and to be kept at bed side. At 2:04pm, V2 (Nurse Consultant / Acting DON) stated that the medication is not supposed to be at the bedside when there is no order to keep them at the bedside. Review of R3's MAR (Medication Administration Record) and `Physician order sheet with V6 showed R3's orders of Deep Sea nasal 0/65% spray aerosol scheduled to be instill 2 (Two) sprays in both nostrils every 4 (Four)hours, Albuterol sulfate HFA 90mcg/actuation aerosol inhaler to be dispensed inhale 2 puffs by mouth every six hours as needed, Artificial Tears (pg400-hypromeliglycerin) 1%-0.2%-2% to be instill every 2 drops every 4 hours as needed for dry eyes, Fluticasone propionate 50 mcg/actuation nasal spray, suspension with instruction to instill one (1) spray in both nostrils at bedtime scheduled for 9:00pm. All the medication shows no physician order to keep at bedside. 145415 Page 8 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0761 Level of Harm - Minimal harm or potential for actual harm R2's electronic medical record Face Sheet showed listed diagnosis information that includes but not limited to cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral atherosclerosis, major depressive disorder, mild intermittent asthma, dementia in other diseases classified elsewhere, unspecified severity with psychotic disturbances, pain unspecified, pain in right shoulder, shortness of breath and chronic obstructive disease. Residents Affected - Few R3's electronic medical record face sheet showed listed diagnosis information that includes but not limited to epilepsy, unspecified, not intractable, without status epilepticus, other muscle spasm, anxiety disorder, gastro-esophageal reflux disease without esophagitis, pain unspecified, vitamin deficiency unspecified, essential (primary) hypertension, chronic obstructive pulmonary disease, drug induced diabetes mellitus with diabetic nephropathy, unspecified hemorrhoids, generalized abdominal pain, major depressive disorder recurrent unspecified, nasal congestion, and dry eye syndrome. On 1/24/24 at 11:12am, V2 stated that with medication being left at the bedside, we don't encourage that. V2 medications should not be left at the bedside in the rooms without orders. On 1/30/24 at 1:08pm, R3 noted in bed, on the bedside table noted two (2) plastic medication cup containing a total of seven (7) medications. R3 stated those are my medicine and the nurse gave them to me. R3 identified the nurse as V19 RN (Registered Nurse). R3 stated I (R3) was not ready to use them when (V19) gave them to me. I will use it please don't let them be mad at me. At 1:12pm, V20 LPN (Licensed Practical Nurse) who was present on the floor stated V19 RN (Registered Nurse) was on break. V20 stated that no medication should be left at the bedside without physician order and the nurse must witness the resident taking the medication. The surveyor asked V20 to count how many medications were in the cup, after counting V20 stated there were 7 (seven) pills but was unable to identify the pills by name. At 1:15pm, V2 (Nurse Consultant/Acting DON) stated that the medications should not be left at the bedside without physician order to do so. V2 stated in part that the family member is not allowed to just bring any over the counter medication to the resident because all medication being administered in the facility must have a physician order. At 1:16pm, V19 stated that when he (V19) left the medications as R3 was not ready to take them. When asked about the professional standards in medication administration, V19 stated I should not have left the medications on the side table. V19 confirmed that he left 7 (seven) medications in total and they were all the afternoon medications and not the AM (Morning) Medications. Facility policy on Medication Administration and Storage with revised date 08/22 presented documented in part that the policy is to ensure medications are administered and stored in accordance with standard of practice. Procedure listed includes but not limited to no medication may be given without a physician's order, self-administration of medications by residents is permitted only when resident has been assessed and is capable of self -medication administration and a physician order has been written for self-medication administration. The facility presented pharmacy Medication Storage in Facility policy with effective date July 2018 documented in part under storage of medications that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Procedures listed includes but not limited to medications supplies are locked when not attended by persons with authorized access. 145415 Page 9 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0761 Level of Harm - Minimal harm or potential for actual harm The facility policy on Self-Administration of Medication documented in part that Each resident has a right to self-administer drugs unless the interdisciplinary team has determined each resident that this practice is unsafe. The interdisciplinary team must assess the resident should a resident choose to self-medicate. Residents Affected - Few 145415 Page 10 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to ensure that the facility temperature in the common areas on the 2nd and 3rd floor meet the required temperature of between 71-degree Fahrenheit to 81-degree Fahrenheit. This failure has the potential to affect all residents residing on the 2nd and 3rd floor of the facility. Findings include: On 01/23/23 at 12:56pm, V5 (Wound Care Nurse) stated that most of the residents have been complaining that the dining rooms are cold, and the staff can feel it in the hallways and dining area. V5 stated this was reported to V4 (Maintenance Director). V4 identified R13 one of the residents actively complaining about the room temperature. V5 stated R13 has being complaining since sometime last week. On 01/23/23 between 1:00pm to 2:00pm, during environmental rounds with V4 (Maintenance Director) regarding facility temperature. The following observations were made: At 1:00pm-Temperature measures on the 3rd floor the [NAME] Hallway 69.2-degree Fahrenheit, South Hallway 67.1-degree Fahrenheit, Dining room =69.0-degree Fahrenheit. When V4 was asked about what the required range of temperature, V4 stated between 73 to 76 degrees. V4 acknowledge that these temperature readings are below the required range of 73 degrees. V4 stated that some of the residents would be cold at that temperature but not all of them. At 1:13pm on the 2nd floor, the South hallway 68.2-degree Fahrenheit and the dining room measures 67.4. At 1:21pm the surveyor asked V4 about how often the facility temperature is monitored. V4 stated I (V4) take it twice a week. V4 stated in part that yes, I (V4) should have it done daily. V4 stated the facility temperature has not been taken today stating but we are doing it now. On 1/23/23 at 3:00pm, V4 was unable to present any documentation that showed that the temperatures had been corrected. V2 who was present at this time then turned to V4 asking V4 to go and start working on correcting this observation. On 1/24/24 at 3:18pm, interview with V5 LPN (Licensed Practical Nurse) about how many residents uses the dining, V5 stated all the residents on the floors used the dining room if not for dining it is for activities. The facility policy presented with revised date 1/16 titled Room Temperature Checks documented that the policy is to ensure proper room temperature is maintained at the acceptable range. Procedure listed includes that the room temperature must be maintained at the acceptable range of 71 to 81 degrees Fahrenheit. The room temperature that falls below the acceptable range of 71 degrees Fahrenheit 145415 Page 11 of 12 145415 01/31/2024 Irving Park Living & Rehab Ctr 4340 North Keystone Chicago, IL 60641

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some listed steps to be taken includes but not limited to the staff will monitor the heating unit (winter) to ensure it is in proper working condition. And the retake of room temperatures will be reflected on the temperature log form. The facility policy on titled Director of Environment Services presented as the Job description for Maintenance Director documented in part that the primary purpose of the position is to plan, organize, implement, evaluate and maintenance departments in accordance with current, federal, state and local standards guidelines, and regulations governing the facility and as directed by the administrator to assure that the facility is maintained in a safe and comfortable manner. 145415 Page 12 of 12