Inspection·December 2, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interviews and review of records, facility failed to follow their policy to ensure family members were notified of resident's change in condition for one (R1) out of three residents reviewed for right to be notified of changes, in a total sample of 3. Findings include: On 11/30/2024, at 9:30 AM, V3 (R1's POA/Complainant) stated that she is R1's POA (Power of Attorney) with her husband. V3 stated that she had requested a report from the facility on what happened to R1 the night he was sent to the hospital. V3 stated that she requested R1's report of the transfer to the hospital on November 5th, 2024, and still has not received an update. On 11/30/2024, at 9:50 AM, V1 (Administrator) stated that V3 requested a report from them on 11/5/2024, regarding what transpired with R1 on 10/31/2024; he was sent to the hospital. V1 stated she notified V2 right away. On 11/30/2024, at 10:00 AM, V2 (Director of Nursing) stated that R1 was a resident on the 3rd floor. V2 stated that on Thursday, sometime in October, R1 was sent out to the hospital because he said he wanted to jump out of the window. V2 stated that she was notified by V1 (Administrator) via email about V3's request on 11/5/2024, regarding R1's incident that took place on 10/31/2024. V2 stated that she called V3 that same day to update her on what happened. When surveyor asked for documentation, V2 presented surveyor with a facility concern form that was hand-written, without any name of the resident on the form or signature of R1 or V3. V2 stated that she did not document on R1's electronic health record progress notes about the update to V3. V2 stated that a facility concern form is not the resident's electronic health record. V2 also stated that if it is not documented in the resident's electronic health record that means the action is not done. V2 stated that from now on she will make sure to document in their progress note any time we notify the family. Reviewed facility's concern/compliment form for notifying V3 on R1's change in condition on 10/31/2024. The form does not have name of the resident, name of the person sharing the concern, date, or signature of R1 or V3. Reviewed R1's progress notes. No documentation of facility notifying R1's family on the details of R1's hospitalization on 10/31/2024, due to suicidal ideation. Reviewed email from V3 (R1's POA) on 11/5/2024, requesting a report from incident on 10/31/2024. (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 12/02/2024 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)