Inspection·April 13, 2025

F 0689 On 04/12/2025, at 11:11 AM, V6 (Certified Nursing Assistant-CNA) V6 stated when moving a resident with a mechanical lift, staff must concentrate and watch what they are doing to prevent resident injury. Level of Harm - Actual harm Residents Affected - Few On 04/12/2025, at 1:00 PM, V9 (Licensed Practical Nurse -LPN) via phone stated she was the nurse for R1 on 3/17/2025, when R1 sustained an injury on the right small toe during transfer. V9 stated she was in the hallway when V10 and V11(CNAs) were transferring R1 from the specialized chair to the bed using a mechanical lift. V10 called her to R1's room because R1 was bleeding from the right small toe. V9 stated V10 and V11 told her that R1 became impulsive during transfer, was moving around and hit his foot on the bed frame. V9 stated she assessed R1 and gave R1 a pain medication. V9 notified V3 (Director of Nursing) then notified V12 (Physician) who gave V9 orders to send R1 to the local hospital for further evaluation. V9 stated she called the hospital later that evening and was informed R1 had received sutures on the right small toe. V9 stated a mechanical lift is used to transfer residents so that residents can be safe and not sustain injuries. On 04/12/2025, at 1:40 PM, V10 (Certified Nursing Assistant-CNA) via phone stated on 3/17/2025, he was guiding the mechanical lift while transferring R1 with V11(CNA) and V11 was operating the lift. V10 stated he and V11 were transferring R1 from the specialized chair to the bed when R1 started getting agitated, anxious, and was moving around. V10 stated R1's right toe got caught at the end of the foot board. R1's toe was bleeding. V10 stated V9 was notified and came to assess R1. V10 stated dependent residents who need maximal assist for transfer are transferred using a mechanical lift to prevent injuries and falls. On 04/12/2025, at 1:57 PM, V11 (Certified Nursing Assistant-CNA) via phone stated there were two CNAs. V10 and V11 were assisting R1 to transfer R1 from the specialized chair to the bed using a mechanical lift. V11 was operating the mechanical lift and V10 was guiding the lift. V11 stated R1 was getting agitated, scared, and V11 was behind the mechanical lift. V11 does not know what happened or what hit R1 on the foot. V11 stated V10 was the one guiding the mechanical lift sling to the bed when R1's right leg hit the bed. R1 started bleeding on the small toe, and V11 and V10 called V9 to come assess R1. V11 stated there are two CNAs operating the mechanical lift for the safety of the resident to prevent injuries during transfer. R1 is a two person assist. On 04/21/2025, at 2:34 PM, V13 (Nurse Practitioner) via phone stated physical therapy assesses residents for mobility. R1 is a two person assist for mobility safety. V13 stated V12 (Physician) is the one who was notified when R1 had injury to the foot, therefore he (V13) does not have details of the injuries but knows V12 gave orders for R1's sutures to be removed by wound care at the facility. On 04/12/2025, at 3:38 PM, V3 (Director of Nursing -DON) stated mechanical lifts are supposed to be used to be operated by two or more staff for the safety of the resident and staff. V3 stated R1 was new to the facility and was admitted on [DATE]. On 3/17/2025, during the afternoon shift, (V10 and V11(CNAs) were going to move R1 from the specialized chair to the bed using a mechanical lift. V3 stated one staff was operating the mechanical lift and the other was maneuvering R1 while on the lift for safety. R1 has Parkinson's disease and tends to flip over or shake because of Parkinson's disease. V3 stated the goal of using a mechanical lift with two staff is to make sure the resident is safely transferred. V3 stated as V10 and V11 were lowering R1 to the bed, his (R1's) foot hit the foot of the bed and R1 sustained injury to the right fifth posterior digit. V3 stated R1 was lowered to the bed, and assessed by V9 (LPN). V13 (Physician) was notified and R1 sent to hospital for further evaluation. V3 stated R1 come back on 3/18/2025, at 2:15 AM, with three sutures to the right fifth posterior digit with orders to monitor and remove sutures in the facility in seven days by wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 2 of 3 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 04/13/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few V3 stated V10 and V11 should have stopped transferring R1 when they noticed he was agitated/fidgety or anxious and should have notified V9 to assess duty to assess R1 so that R1 could have been transferred safely. On 04/12/2025, at 4:00 PM, V14 (Therapy Director) via phone stated R1 was never assessed by therapy at the facility because he come to the facility as a mechanic lift transfer resident when he transferred to this facility from a sister facility. V14 stated if a resident is dependent and requires two staff to transfer, a mechanic lift is used for safety reasons to avoid injuries during transfer. V14 stated the staff are supposed to monitor the resident so that the resident does not sustain injuries during transfers. The resident is not able to help at all during transfers and the helper does 100% of the work. V14 stated that is why R1 is transferred with a mechanical lift for the safety of R1. V14 further stated she does not expect a resident who is being transferred with a mechanical lift to be injured during transfer because staff are the ones operating the machine and should be monitoring the resident as they transfer to prevent injuries. Policy titled: Hydraulic Lift (Hoyer Lift) no date, documents: PURPOSE -To enable two staff to lift and move a resident safely, with as little effort as possible Nursing progress notes dated 03/17/2025, 5:21 PM document: Around 4:00 PM, two Certified Nursing Assistants (V10, V11) were transferring R1 from the specialized chair to bed using a mechanical lift. R1 bumped his right foot by the foot board during transfer. Upon assessment (by V9-LPN) noted a small laceration to the posterior right 5th digit. First aid was rendered. MD (Medical Doctor-V13) notified, and orders were given to transfer R1 to a nearby hospital for medical evaluation. Nursing progress notes dated 03/18/2025, 2:52 AM, document: R1 returned to the facility from the hospital with DX (Diagnosis) of Foot Laceration. Right foot 5th digit noted with 3 sutures with discharge instruction to remove sutures in one week. Hospital records dated 3/17/2025, documents: -R1 was seen at the emergency department for a concern of a laceration to right little toe and received three sutures to help bring the skin together. Sutures to be removed in one week. R1's care plan dated 3/17/2025, documents: Pressure Ulcer/Injury-Laceration Right Toe Incident -Staff Education/Inservice on Resident safety transfer was given to all nursing staff. R1's care plan dated 3/18/2025, documents: -Resident will be transferred with mechanical lift and sling daily. Verbal cues and two persons assist from staff for resident safety and proper use of device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145415 If continuation sheet Page 3 of 3