F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the
interview and record review, the facility failed to thoroughly and timely investigate a situation of potential
staff-to-resident abuse for one resident (R1) reviewed for physical abuse in the sample of three.
Residents Affected - Few
Findings include:
On 8/20/2024 at 2:00 PM, V3 stated I got a call from the R1 family, and she reported that V5 struck R1 in
the penis on 8/6/2024 while giving patient care, and nothing was being done. She also informed me the
facility has not started working on R1 discharge planning. After speaking with the family, I immediately
came out to visit R1 and informed the facility Administrator on 8/15/2024.
On 8/20/2024 at 11:36 AM, R1 states on the evening of 8/6/2024, the CNA(V5) came to my room. I pulled
the call light because I needed to be changed. I told the CNA I think I had a bowel movement. The CNA
came over to check to see if I was wet and struck me in my private area, and I yelled. I was yelling because
I didn't understand why he would check me like that, and I have a urinary catheter that caused me so much
pain. V6 came in, and I informed her and told her I didn't want V5 taking care of me anymore. He was very
rough with me. I called my sister and told her that night.
On 8/21/2024 at 11:17 AM V1(Administrator)states, initially this was reported as a concern on the 8/6/2024
that V5 touched the catheter which caused pain and V5 did not know he had catheter. V6 reported to
ADON. ADON spoke to V2 and there was a concerned filled out for patient care. Staff made sure V5 was
not scheduled to work that set. R1 reported to the nurse that everything was okay. On 8/15/2024, the
ombudsman came in and reported to me that the family called and informed him that he was struck by
[NAME] while giving patient care. I interviewed R1, and he showed me how he was checking his diaper,
and he was touching the catheter, and that it hurt, and he didn't want [NAME] taking care of him. He reports
[NAME] struck him while checking to see if he was dry. The resident reported he allowed [NAME] to change
him. I immediately started my investigation and reported that to IDPH.V5 was suspended until further
investigation. Final was sent this Monday 8/19/2024 to IDPH and completed full investigation 8/16/2024. All
staff, clinical or non-clinical, should report any allegations of abuse.
On 8/21/2024 at 9:20 AM V2 states, V9 informed me that R1 family called 8/7/2024 and reported V5 was
rough with this resident during patient care on 8/6/2024. At the time, we viewed this as a concern and made
sure V5 was no longer assigned to take care of R1.V5 also completed an in-service. On 8/15/2024, the
ombudsman notified my administrator that the family had called in to report that V5 had struck R1 in the
groin area. If a resident informs the nurse that a staff member is being rough or reports any abuse, this
should be reported immediately to the administrator.
(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:
145415
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
145415
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Irving Park Living & Rehab Ctr
4340 North Keystone
Chicago, IL 60641
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 8/21/2024 at 11:39 AM, V9(ADON) states, I found out about the incident from V8 (Family). She called in
the late afternoon of 8/7/2024 to speak to a supervisor, so the call was directed to me. V8 was yelling on
the phone and screaming at me stating she didn't want V5 taking care of R1 and she wanted her brother
discharged . She reported that V5 was rough with her brother. I asked the family to explain exactly what R1
reported to her. V8 really didn't want to speak with me. She wanted to speak to the administrator. She did
not report that R1 was struck, kicked or hit by V5. I thought this happened that same day, so I went down to
the second floor to see R1 and V5. I saw V5 in dining area feeding residents and I ask what happened the
night before with the R1. The sister just called and reported you were being rough with the resident. V5
reported it happened yesterday. He was trying to see if R1 had a bowel movement. He saw call light on,
and he went to check him V5 reported he was unaware R1 had a foley catheter in so he took off brief the
resident yelled that hurt and I have a catheter why would I be wet. R1 reported to V6 that he was being
rough with him.
No documentation in the medical record regarding the allegations reported dated 8/6/2024.
Reviewed 24-hour incident investigation report started 8/15/2024.
Reviewed final report dated 8/19/2024.
Facility policy date 10/22/2024 titled Abuse Prevention Policy documents in part, section V, employees are
to report any incident, allegation or suspicious of potential abuse, neglect, exploitation, mistreatment or
misappropriation of resident property they observe hear about, or suspect to the administrator immediately.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145415
If continuation sheet
Page 2 of 2
