Inspection·May 27, 2023

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on interview and record review, the facility failed to ensure that a resident Physician or designee's progress notes are maintained in the facility records. This applies to 1 of 3 residents (R1) reviewed for Improper Nursing Care in the sample of 6. The findings include: R1's EMR (Electronic Medical Records) included diagnoses of chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity, peripheral vascular disease, morbid (severe) obesity due to excess calories, cellulitis of left lower limb, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. R1's Annual MDS (Minimum Data Set) dated 3/14/2023 showed that R1 was cognitively intact. On 5/26/23 at 9:40 AM, R1 stated that the residents are supposed to have visits from the PCP (Primary Care Physician) and hasn't seen one for over a year. R1 stated that he is seen by the Infectious Disease NP (Nurse Practitioner) one-two times a month or more often if he is fighting an infection. R1 stated that his Palliative Care NP sees him weekly routinely. R1 remarked that his PCP V8 and her team communicate with the nurse, and we are taken out of the loop and are in the dark. On 5/26/23 at 10:29 AM, V7 (Registered Nurse) stated that R1's PCP V8's practice has V9 NP and V10 (Physician Assistant) who come to see her patients. V7 added that V9 comes every Friday and sees patients that are on the list. On 05/26/23 at 2:58 PM, V6 ADON (Assistant Director of Nursing) stated that the facility follows the policy for residents to be seen routinely by PCP and NP or PA. V6 added that the NP's that are with Infectious Disease or Palliative Care are not under V8's Practice. Review of R1's EMR (on 05/26/23) for past six months did not show V8's or her support team's progress notes. Per request from facility V9's late entry (dated 05/26/23) progress notes and plan of care were obtained from V9 showing visits with R1 dated 12/05/22 and 05/05/22. On 5/27/23 at 10:17 AM, V3 (Assistant Administrator) stated that she has reached out to V8's office to obtain records of her visits. On 05/27/23 at 1:41 PM, V8's late entry (dated 5/27/23) progress notes and plan of care were obtained from V8 showing visits with R1 dated 1/5/23, 3/02/23 and 4/27/23. (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: 145379 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 145379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Valley Ridge Rehab & Hcc 275 East Army Trail Road Bloomingdale, IL 60108 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)