Inspection·March 28, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect and secure the confidential personal medical records of a resident by allowing an unauthorized individual to obtain resident medical records. This failure applied to one of one (R72) residents reviewed for medical records. Residents Affected - Few Findings include: R72 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, occlusion or stenosis of unspecified cerebral artery, vascular dementia, and type II diabetes mellitus. On 03/25/2024 at 12:00pm, V4 (Family Member) said about two months ago, the facility gave confidential records belonging to R72 to an unauthorized family relative. V4 further said the relative posed as V4 and convinced facility staff to hand over the personal medical documents. On 03/27/2024 at 1:45pm, V3 (Assistant Administrator) said on 02/03/2024, a person impersonated V4 at the facility and an agency nurse gave R72's medical information, specifically, R72's progress notes and care plan, to him. V3 said there were family dynamics within R72's family. V3 said after the breach occurred, R72's power of attorney and V4 were notified, and the family member that posed as V4 was banned from the facility. V3 said the agency nurse that gave R72's medical information to the unauthorized family member failed to fill out a medical release form needed to request the information, and added that it happened on a weekend when the weekend manager was on duty. V3 said the assistant director of nursing was notified, as well as the responsible nurse's agency, and in-service education was provided to staff. V3 lastly said attempts were made to try to get the released medical documents back from the relative but he did not return them. Facility provided a Concern Response Form dated 02/03/2024 and filled out by V3, which read: reported that his cousin pretended to be him and requested medical records from the nurse on duty. The form further states the assistant director of nursing told the administration team who told V4 they would, follow compliance process and submit breach to OCR (Office for Civil Rights) and AG (Attorney General). The facility's, Medical Records Request and Access policy dated 10/17/2018, states in part, the resident or legal representative of the resident will be allowed access to inspect resident's medical records within 24 hours of a valid oral or written request to the Administrator excluding weekends or holidays. 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 3 Event ID: 145931 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 145931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076 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)