Health inspection·February 18, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility failed to maintain a resident's (R2) rights to privacy and confidentiality of personal and medical information for 1 of 3 residents reviewed for residents' rights. Residents Affected - Few Findings include: On 02/16/2024 at 3:00 PM, V8 (R1's Power of Attorney for Healthcare) stated during R1's discharge, V9 put a bunch of medications in a bag and gave it to V8 without individually going through each medication blister pack. V8 did not realize R2's medications were also in the bag until a few days later. V8 received blister packs of R2's Escitalopram Oxalate 5 MG (milligram) and Levothyroxine 50 MCG (microgram). V8 stated the blister packs contain R2's name, doctor, medication name, dosage, and why R2 is on the medication depression and hypothyroidism. V8 provided a picture of R2's medication label for Levothyroxine 50 MCG and Escitalopram 5 MG. Levothyroxine label documents in part prescription number, date of 11/22/2023, R2's previous room number, R2's name, medication name, dosage, frequency, and indication-hypothyroidism. Label also documents in part the pharmacy name and V10's (R2's Primary Physician's) name. The Escitalopram label documents in the prescription number, date of 12/02/2023, R2's current room number, R2's name, medication name, dosage, frequency, and indication-depression. Label also documents in part the pharmacy name and V10's (R2's Primary Physician's) name. On 02/18/2024 at 1:25 PM, V1 stated facility uses the pharmacy that was in the photo. R2's face sheet and physician orders document in part a medical diagnosis of hypothyroidism. R2's physician order sheets and medication administration records document in part an order for Escitalopram Oxalate Tablet 5 MG (milligram) Give 1 tablet by mouth one time a day for Depression and Levothyroxine Sodium Oral Tablet 50 MCG (microgram) Give 1 tablet by mouth in the morning for hypothyroidism. On 02/18/2024 at 8:36 AM, V4 (Nurse) stated the facility's medication blister packs for the residents contain the resident's name, room number, primary physician, medication name, dosage, frequency, and resident's diagnoses or indication as to why the resident is taking the medication. On 02/18/2024 at 10:58 AM, V7 (Memory Care Director) stated R1 and R2 were roommates. V7 stated there was no relation to the two. V7 stated R1's family or representatives should not have access to R2's personal or medical information. V7 stated only the people listed on the resident's face sheet should have access to the resident's personal information. Additionally, the resident or guardian will (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: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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)