Health inspection·November 22, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, Facility failed to follow their policy to be free from sexual abuse by not providing necessary care and services. This failure resulted in a male resident (R4) sexually assaulting another male resident (R3). This failure affects two (R3 and R4) out of three residents reviewed for sexual abuse. Findings include: R3's MDS (Minimum Data Set) dated (10/1/2024) documents in part R3's BIMS (Brief Interview for Mental Status) score is 15. R3 is cognitively intact. R3's face sheet documents the medical diagnoses: Generalized epilepsy, viral hepatitis, spinal stenosis, chronic pain, hypothyroidism, gastroesophageal reflux disease, metabolic encephalopathy, essential hypertension, depression, type 2 diabetes mellitus, osteoarthritis, anxiety disorder. R4's is only alert and oriented to person and place. R4 is not alert. R4's face sheet documents the following medical diagnoses: dementia with behavioral disturbances, cognitive communication deficit, cerebral infarction with residual deficits, bipolar disorder and Schizophrenia. On 11/20/2024, at 11:10 AM, the surveyor observed R3 in his bed in his room. R3 was not in any pain. R3 stated that R4 had many behavioral and mental issues. R3 stated that one night, R4 came onto his side of the bed and then put his hands down on R3's diaper. R3 stated that he hit R4's hand out and told him to go sit on his bed and then pressed the call light. R3 stated that R4 went and sat on his bed. R3 stated that at that time the CNA (Certified Nursing Assistant) came in and saw R4 sitting on his bed. On 11/20/2024, at 11:15 AM, the surveyor observed R4 lying in his bed. R4 was not in any pain or discomfort. R4 stated he has no concerns with abuse, nor has he abused anyone else. R4 stated he has not sexually touched anyone inappropriately. On 11/20/2024, at 12:36 PM, V4 (Certified Nursing Assistant) stated she is familiar with the incident between R3 and R4. She was working on the floor, and it was in the morning around 4:00 AM. V4 stated R3 pulled his call light. When V4 came in, R3 stated R4 tried to touch him inappropriately. V4 stated when she walked in and, she saw R4 sitting on his bed. V4 stated that she told the nurse. V4 stated that they then moved R4 to a different room until they could figure out what to do next with R4. V4 stated that, she has heard that in the past R4 has tried to touch others inappropriately. Reviewed reportables for the past year. R4 had a previous incident of touching someone else inappropriately on 05/28/2024. (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 11/22/2024 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)