Health inspection·December 27, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews the facility failed to protect the rights of every resident to be free from verbal or physical abuse for 1 out of 4 residents (R1) reviewed for resident rights to be free from abuse. These failures do not conform with the abuse policy of the facility. Failures affected 1 resident (R1) that had directed verbal aggression and was poked in the hand by R2. Findings include: R1 an [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/02/2024, scored 13. R1 is alert. R1's diagnosis includes dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2 [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/03/2024, scored 14. R2 is alert. R2's diagnosis includes dementia, psychotic disturbance, major depressive disorder. Per facility's incident report investigation with initial date of 12/02/2024, and final date of 12/06/2024, it documents that abuse was founded. R1 stated on 12/01/2024, her roommate R2 was throwing tissues on the floor, threw a cup of water on the floor and tapped/poked her hand. Per social services notes of V4 (Assistant Director of Social Services) dated 12/01/2024, at 3:42 PM, documents that R2 was exhibiting increase agitation being verbally aggressive towards R1. R2 verbalized that she was upset with R1 because R1 placed her items on her meal tray. R2 became physically aggressive with R1 by tossing the cup on the floor. Per nursing notes of V5 (Licensed Practical Nurse) dated 12/03/2024, at 8:49 AM, documents that R1 informed V5 about her finger. R1 was asked how she injured her finger? R1 stated, Yesterday my roommate poked my hand. Written statement of V6 (Licensed Practical Nurse) dated 12/02/2024, documents that when she asked R1 how she got the skin tear to her finger? R1 verbalized that her roommate (R2) had it her on her left hand yesterday (12/01/2024) causing her some bruising. Per nursing notes of V3 (Licensed Practical Nurse) dated 12/05/2024, 9:25 AM, documents that when R1 was asked how she injured her finger? R1 stated, Yesterday my roommate poked my hand. On 12/24/2024, at 11:55 AM, V3 stated that she cannot determine whether it was left or right of R1 (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 12/27/2024 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)