Health inspection·March 19, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review the facility failed to ensure that staff are aware of the requirements for involuntary (psychiatric) admission, failed to provide resident a petition for involuntary admission and failed to explain the rights of admittee for one of four residents (R1) reviewed for transfer/discharge. Findings include: R1's (2/5/25) petition for involuntary/judicial admission states resident was in an alleged physical altercation with co-peer, both patients were separated however he continues to attempt to become physical. Resident had to be removed from the area to a lower floor but would not comply to separate from co-peer therefore MD (physician) was made aware with order to send to hospital to prevent provoking and harm to others. [Page 3 was endorsed by V7/Social Service Director]. Page 4 states Within 12 hours of admission to the facility under this status and/or completion of a new petition, I gave the respondent a copy of this petition (IL462-2005). I have explained the Rights of admitted to the respondent and have provided him or her with a copy of it. I have also provided him or her with a copy of Rights of Individuals Receiving Mental Health and Developmental Services (IL462-2001) and explained those rights to him or her (405 ILCS 5/3-609). I certify that I provided respondent with a copy of this form. Date/Time of admission to Mental Health Facility/Psychiatric Unit: ____. Date/Time Petition Completed: ____. Signed: ____. Page 5 states I certify that I provided respondent with a copy of this form. On: ____. Time: ____. Signature: ____. On 3/13/25 at 11:30am, surveyor inquired why R1 was sent to the hospital on or about 2/5/25, V7 stated I (V7) think that's the incident between him (R1) and (R2). He (R1) was the aggressor. Surveyor inquired about the requirements for involuntary petition, V7 responded We (staff) did the petition for him to go out. I (V7) wrote a petition, they (staff) had to call the doctor to get the order for an evaluation. Once I write the petition I give it to the nurses, the nurses do the rest. Surveyor inquired who receives the petition for involuntary/judicial admission, V7 replied Usually it goes to the ambulance driver. We make 3 copies one for the hospital, one for the ambulance and the other one I'm not sure. Surveyor inquired if R1's (2/5/25) petition for involuntary psychiatric admission was signed by the Nurse to determine if R1 received a copy and/or was made aware of his rights, V7 stated No. Surveyor inquired if R1's involuntary petition was documented in the progress notes, V7 responded It should be a note. R1's (2/5/25) progress notes state MD (Medical Doctor) gave order to transfer resident to hospital for psych (psychiatric) evaluation. Call placed to hospital, report given to intake Nurse with Petition, face sheet and POS (Physician Order Sheets) was faxed to hospital as requested. [Petition provided to R1 and/or explanation of rights were excluded]. (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 5 Event ID: 145479 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 145479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Health Care Center 1425 West Estes Avenue Chicago, IL 60626 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)