Inspection·July 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few floor. The nurses assessed R2 and we put her into the wheelchair. Typically, I make rounds when I get to the nursing unit, but I was getting my assignment. R2 has fallen in the past. R2 needs close monitoring all the time. R2 fell during shift change when everyone was at the nursing station, third shift and first shift staff.On 7/17/25 at 10:50 AM, V16 [Certified Nurse Assistant] stated, I was the night shift aide, worked on 6/3/25, when R2 fell. I provided care to R2 around 6:00 AM. Around 7:10 AM, all the first-floor staff was at the nursing station when we heard a noise. I ran into R2's room and she on the floor. R2 left side of her face was discolored dark. R2 needs close monitoring. R2 needs to go to the bathroom frequently and it takes a long time to take her. R2 knows how to place on her call light sometimes, but she does not wait for assistance, she will try to take herself and will fall. Some of R2's fall interventions are, close monitoring, floor mats, low bed and keep the call light in reach. R2 constantly tries to transfer herself all the time.On 7/17/25 at 12:30 PM, V14 [Licensed Practical Nurse] stated, I was R2's third shift nurse. Around 7:05 AM the nursing staff was all at the nursing station. I was giving report to the first shift nurse when we heard a noise came from R2's room. The certified nurse assistance went to her room first to check on the resident. I was called to R2's room I saw R2 on the floor lying on her left side. R2 said she was okay, and after assessing her she was placed into her wheelchair noted with her left side of face was discolored dark. R2 requires constant supervision. Through the night shift the Certified Nurse Assistant sits in a chair outside R2's room to provide one to one monitoring. R2 pulled the call light, but before someone was able to answer her call light, she tried to transfer herself. This happens all the time. I saw her last around 6:00 AM, she was resting in bed. The first shift nurse took over and notified the physician, family, and administration. On 7/17/25 at 2:00PM, V15 [Registered Nurse] stated, I was R2's nurse on 6/3/25, working first shift. I was at the nursing station waiting to get nurse report. Certified Nurse Assistant came and said R2 was on the floor. Everyone ran into R2's room. R2 was lying on the floor with a bruise to her left side of her face. R2 said she was okay. R2 vital signs were with in normal range, and I started neuro checks. R2's physician gave an order to send R2, to the emergency department. Later, the hospital called and said R2 had a left eye orbital fracture. I notified the administration. R2 needs frequent supervision and monitoring. When R2 places on the call light, you have to answer call light immediately or R2 will try to take herself to the bathroom and fall.On 7/16/25 at 11:00 AM, V2 [Director of Nursing/ Fall Coordinator] stated, I been working here since 1/16/25 as the Director of Nursing and Fall Coordinator. On 6/3/25, during shift change, staff heard a noise, went to R2's room and observed her laying on the floor and noted with left side facial discoloration. R2 was sent to the emergency department and R2 was diagnosis with a left orbital eye fracture. R2 had a total of five falls with two falls resulted in an arm fracture and then a left orbital eye fracture. R2 needs supervision, close monitoring, practically one to one supervision. The facility is not able to provide R2 with a one-to-one sitter all the time. R2's fall interventions should be patient centered for each fall to assisted in preventing another fall.On 7/18/25 at 11:00AM, V18 [Physician] stated, R2 is very confused with left sided weakness and need close supervision. R2 has anxiety and needed antianxiety medication. R2's power of attorney refused for R2 to take antianxiety medication. During the examination of R2, it takes two staff members to assist me, because R2 is always trying to get up. R2 had an arm fracture from a fall, and recently a left eye orbital fracture. The falls were avoidable, if R2's power of attorney would have allowed R2 to take antianxiety medication to help her.Policy documents in part:Falls and Fall Prevention:To ensure a fall prevention program will include measures which will determine the individual need of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary (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 07/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete supervision and assistive devices as indicated based on assessment.Resident will be reassessed quarterly and after each fall.Immediate change in intervention that were successful.Documentation as indicated.Resident fall risk intervention will be identified on the care plan.The frequency of safety monitoring will be determined by the resident's risk factors and care plan.Resident care plan intervention will be as indicated.IDT [Team] to discuss post incident/accident and or fall incident to ensure prevention from reoccurring. Event ID: Facility ID: 145415 If continuation sheet Page 3 of 3