Irving Park Living & Rehab Ctr

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and protect a resident from staff to resident abuse. This failure affects two (R1, R6) residents out of six residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate supervision for one cognitive impaired resident (R2) who is a high fall risk with a history of falls with injury out of a sample of four [R1, R3, R4] residents reviewed for falls. This failure resulted in R2 falling, transferred to the emergency department, and sustained a left eye orbital fracture. Findings Include, R2 's clinical record indicates the following in part: R2 was admitted with hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, essential hypertension, vitamin D deficiency, restlessness, history of falling, type II diabetes, anxiety disorder, depression, and fracture of upper end of left humerus. R2's minimum data set [MDS] Section [C] Brief Interview Mental Status score [11]. Indicates R2 is mildly cognitively impaired. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to safely transfer one (R1) of three residents reviewed for mechanical lift transfer. The failure cause R1 to sustain injury to his right fifth toe requiring three sutures.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) discard expired food based on use by guidelines and date, c.) sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 75 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 78 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure (a) hand hygiene was performed between each resident contact during medication administration; (b) proper PPE (Personal Protective Equipment) was worn during a High-Contact Resident Care Activity (gastric tube flush) for a resident on Enhanced Barrier Precautions; (c) proper handling and storing of linens; (d) ensure IPCP (Infection Prevention and Control Program) standard policies and procedures are reviewed at least annually. These failures could affect all 78 residents residing in the facility as of census dated 1/14/25.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a $60 monthly allowance to eligible residents receiving SSA (Social Security Administration) since the increase from $30 to $60 in January 2024. This failure affected 16 eligible residents receiving SSA allowance per resident fund management service (RFMS) dated 1/3/25 in a sample of 48 residents.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment [A] failed to maintain hot water temperatures for six [R24, R25, R52, R57, R58, R73] resident's rooms and the third-floor shower room, [B] failed to maintain a safe smoking patio environment related to not removing snow and ice for six [R25, R38, R52, R53, R73, R74] residents outside smoking reviewed in a sample of 18 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) to ensure medications were securely stored during medication administration, b,) ensure expired medications were removed from 1 of 2 medication storage rooms and 1 of 3 medications carts and c.) ensure medication was labeled after opening for 1 of 3 medication carts reviewed for medication storage and labeling. Findings Include: On 01/14/25 at 09:25 AM V4 (Registered Nurse) prepared and administered medication standing at the medication cart to R38 in a medication cup and supplied R38 with a cup of water. During R38 medication preparation V4 wasted (Aspirin 325 mg (milligram)) orange pills in the top drawer of the medication cart. V4 put on gloves then placed the pills in a clear drinking cup (half full) and placed the cup on top of the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect seven residents (R9, R10, R31, R35, R47, R56) receiving pureed diets prepared in the facility's kitchen based on list of residents receiving pureed diets dated 01/16/25 in a sample of 48. Findings Include: On 01/14/25 at 11:52 PM, during unit dining tours observed residents on regular diet consistencies receive roast turkey, egg noodles, mixed vegetables, fruit cup, and bread with margarine. Observed R9, R31, R35, R47, R56 who were on pureed diets receive pureed turkey, mashed potatoes, pureed vegetable, and pureed dessert. Pureed bread was not served. Pureed buttered noodles were not served. On 01/14/25 at 12:07 PM, observed lunch tray line in the kitchen still in progress with V12 (Cook) serving the food. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide fortified supplement as prescribed by the physician for six (R4, R10, R15, R23, R34, R55) residents reviewed in a total sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations; (2) assess eligibility and offer pneumococcal vaccinations to five (R10, R11, R18, R25, R35) of eight residents reviewed for pneumococcal vaccinations in a sample of 48 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy and procedure to ensure advance directives are included in residents' comprehensive care plans and updated as indicated for three (R32, R47, R63) out of 12 residents reviewed for advance directives in a final sample of 48 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards for a PICC (Peripherally Inserted Central Catheter) line for 1 (R130) of 3 (R17, R132) sampled residents related to the maintenance of intravenous access devices. Findings Include: R130 has diagnosis not limited to Encounter for Other Orthopedic Aftercare; Primary Generalized (Osteo)Arthritis; Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Hyperlipidemia, Hypothyroidism, Polycythemia Vera, Bipolar Disorder, Effusion, Right Knee, Pyogenic Arthritis, Klinefelter Syndrome, Spinal Stenosis, Testicular Hypofunction, Depression, Retention of Urine, Morbid (Severe) Obesity, Iron Deficiency Anemia and Muscle Spasm. R130's Care Plan document in part: Focus: Intravenous Therapy: Antibiotic therapy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a tracheostomy had the required emergency equipment at the bedside for 1 (R17) resident reviewed for respiratory care in a sample of 48. Findings Include: R17 has diagnosis not limited to Tracheostomy, Chronic Respiratory Failure, Gastrostomy, Dysphagia, Morbid Obesity, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, Hypertensive heart disease, Epilepsy, Shortness of Breath Type 2 Diabetes Mellitus and Primary (Essential) Hypertension. R17's Physician's Orders document in part: Tracheostomy tube changes every 3 months and prn (as needed). (Tracheostomy tube) 6 as needed. Change Inner Cannula (Tracheostomy tube) 6 once daily and prn. R17's Care Plan document in part: Focus: Tracheostomy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure the accurate shift change reconciliation accountability record for controlled substance and b.) ensure an accurate accountability for 2 controlled substances (Clonazepam/Tramadol) by resolving discrepancies in a timely manner. This deficient practice was identified for 1 of 3 medication carts used to store controlled narcotics. Findings Include: Document titled Shift Change Accountability Record for Controlled Substance document in part: 2nd Month-Year January 2025: nurse Initials were missing for 01/13/25 second shift, third shift and 01/14/25 first shift. R9's Control Drug Receipt/Record/Disposition Form: document Date received 07/19/24, Drug Name/Strength: Tramadol HCL Tab 50 mg (Milligrams), Directions: One tablet by mouth every 6 hours as needed for pain. Quantity Received: 30. Amount Left: 16. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received the prescribed amount of insulin for 1 (R25) resident reviewed for significant medication error in a sample of 48. Findings Include: R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerators, c.) ensure resident refrigerators are in proper working order. This has the potential to effect one resident (R53) out of six residents reviewed for personal food storage in a total sample of 48.

Inspectors wroteBased on review of records and interviews the facility failed to protect the rights of every resident to be free from verbal or physical abuse for 1 out of 4 residents (R1) reviewed for resident rights to be free from abuse. These failures do not conform with the abuse policy of the facility. Failures affected 1 resident (R1) that had directed verbal aggression and was poked in the hand by R2.

Inspectors wroteBased on interviews and review of records, facility failed to follow their policy to ensure family members were notified of resident's change in condition for one (R1) out of three residents reviewed for right to be notified of changes, in a total sample of 3.

Inspectors wroteBased on interview and record review, Facility failed to follow their policy to be free from sexual abuse by not providing necessary care and services. This failure resulted in a male resident (R4) sexually assaulting another male resident (R3). This failure affects two (R3 and R4) out of three residents reviewed for sexual abuse.

Inspectors wroteBased on the interview and record review, the facility failed to thoroughly and timely investigate a situation of potential staff-to-resident abuse for one resident (R1) reviewed for physical abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from sexual abuse. This failure affected 1 resident (R1) in the sample of 8. This failure resulted in R1 experiencing psychosocial harm by feeling violated and victimized by R2 due to R2's unwanted touching.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a as needed (PRN) dose of pain medication was administered to a resident for breakthrough pain which affected one (R3) resident in the total sample of 8 residents reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the residents' rooms temperature are within the required comfortable and safe degrees Fahrenheit of between 71 to 81 degrees for 37 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) reviewed for comfort and safe environment. This failure affected (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) residing on the 2nd and 3rd floor and has the potential to affect all 86 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the facility temperature in the common areas on the 2nd and 3rd floor meet the required temperature of between 71-degree Fahrenheit to 81-degree Fahrenheit. This failure has the potential to affect all residents residing on the 2nd and 3rd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders and apply hand splint/brace for two of six residents (R2 and R4) with limited range of motion and failed to provide documentation related to application refusal of splint/brace. This failure affected R2 and R4 reviewed for assistive devices in the total of 86 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the residents environment remains free of accidental hazard by not leaving sharp items, disposable shaving razor and scissors that could harm the residents at the bedside. This failure affected R2 who had scissors on the bed and visible to the hallway and R12 who had disposable shaving razor on the bedside table. This has potential to affect all the residents residing on the 2nd and 3rd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide enough staffing to meet the needed restorative services for two of six residents (R2 and R4) with limited ROM/range of motion and who are dependent on staff assistance in applying hand splint/brace devices. This failure affected R2 and R4 whose splint/braces are not applied, and this has the potential to affect all 74 residents identified as residents on restorative program and 22 residents on splint program.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that medication is stored in a locked cart when not in proximity of the nurse for two of three residents (R2 and R3) in the sample reviewed for medication administration. This failure affected R2 and R3 whose medications were left at the bedside without physician order to do so and has the potential to affect all 30 residents residing on the 3rd floor.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to label/date food items, failed to dispose of food items beyond the use by date, failed to ensure freezer' and cooler' temperatures were monitored and logged, failed to ensure staff' lunch bag was not stored in the Kitchen cooler, and failed to ensure the test strips used to check the solution in the sanitize sink was not expired in an effort to prevent food borne illnesses. These failures have the potential to affect all 73 residents receiving oral nutrition at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the outside dumpsters' lids were closed in an effort to prevent pest and rodents from migrating into the dumpster. This failure has the potential to affect all 76 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thermometers for resident's personal refrigerators for 2 residents (R56 and R70), failed to discard expired food from resident's personal refrigerator for 1 resident (R56), and failed to properly log refrigerator temperatures for 3 residents (R56, R74, and R181). These failures affected 3 (R56, R74, and R181) residents reviewed for personal food items in a total sample of 41 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment for one resident (R59) in the sample of 41 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed quarterly for one resident (R64) reviewed in a sample of 41 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive mouth care, grooming and showers as scheduled. These failures affected two residents (R25 and R33) out of 4 residents reviewed for ADL care and grooming, in a total sample of 41 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that an abnormal lab and abnormal blood glucose were relayed to the Medical Doctor for one resident (R41). This failure has affected one of 41 residents reviewed for nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have low air loss mattress at the correct weight settings for a resident with pressure ulcer who is at high risk for further pressure ulcers. This failure affected one resident (R56) of two residents, reviewed for pressure ulcer prevention interventions, in a total sample of 41 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that oxygen tubing was replaced for two residents (R58 and R19). This failure has the potential to affect 13 other residents who receive oxygen or nebulizer treatments in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to label with date a resident central venous line dressing in an effort to prevent infection. This failure affected R180 reviewed for infection control in a total sample of 41 residents.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed ensure 1 [R1] of 3 residents pain medication was available on 1 of 3 medication carts.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the high temperature dish machine reached a temperature of 180F during final rinse and failed to ensure the high temperature dish machine was monitored two times daily. These failures have the potential to affect all 78 residents taking oral nutrition at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to reduce the risk of accidents for 1 resident (R53) of 6 residents reviewed for falls. This failure resulted in R53 sustaining multiple falls and sustained a hip fracture.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide podiatry services for a resident (R9) and have services done every 60 days. These failures affected 9 (R4, R6, R9, R22, R27, R32, R39, R53, R64) residents out of a final sample of 18 residents reviewed for podiatry services and potentially affecting all residents in the facility who require podiatry services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate staffing to provide individual needs such as providing escorts to assist a resident (R68) to appointments. This has the potential to affect all the residents that reside on the third floor.

Inspectors wroteBased on observations, interviews and review of records the facility failed to account all narcotics medication including those provided by hospice for 1 out of 2 medication storage room reviewed for 2 residents (R232 and R233). Failed to follow policy on administration of medication via gastrostomy route to 1 resident (R27). These failures have the potential to affect all 35 residents on the 3rd Floor as it relates to accounting of narcotic medications. And 1 resident (R27) receiving medication via Gastrostomy.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow their policy for storage of medications for 2 out of 3 medication carts and 1 out of 2 medication room for not dating insulin for 1 resident (R40). Failed to maintain medication cart free from expired insulin medication for 1 resident (R31). Failed to lock refrigerator that contains narcotic medication for 3 residents (R73, R232, R233). These failures have the potential to affect 35 residents on the 3rd Floor and 1 resident (R31) on the 2nd Floor receiving insulin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate use of personal protective equipment (PPE) worn by visitors while visiting a resident (R55) with an infectious disease. This failure had the potential to affect all ten residents residing on the first floor of the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide an escort to assist a resident (R68) to outside appointments for 1 of 1 resident reviewed for appointments in a total sample of 18 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to replace R39's wheelchair in a timely manner and ensure R72's call light was within reach affecting 2 of 18 residents reviewed for accommodation of needs.

Inspectors wroteBased on observations, interviews and record review of records the facility failed to follow policy on restraint for 2 of 2 residents (R4 and R27) for a total of 18 reviewed for restraint use.

Inspectors wroteBased on observations, interviews and review of records the facility failed to follow policies for 2 out of 2 residents (R27 and R30) for a total number of 18 residents reviewed for enteral feeding. Failures include 1 resident (R27) Gastrostomy Tube patency check for administering medication was not checked. And failed to determine the need for a Gastrostomy Tube of 1 resident (R30).

Inspectors wroteBased on observation, interview and record review the facility failed to provide call light for 1 (R22) of 6 residents reviewed in a total sample of 18 for call lights.