F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Let each resident or the resident's legal representative access or purchase copies of all the resident's
records.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide requested medical records for one resident (R1) out
of three residents reviewed for medical records request.
R1 has a diagnosis which includes but not limited to: Alzheimer's disease, pressure ulcer of left heel stage
4, Alzheimer's disease with early, onset, dementia unspecified severity without behavioral.
R1's Minimum Data Set (MDS) dated [DATE] shows no Brief Interview for Mental Status (BIMS) score for
R1 which indicates that R1 has some memory impairments.
On 01/16/23 at 1:41 pm, V10 (R1's Family Member) stated that R1's family requested R1's medical records
from the facility in December 2023. V10 stated that V10 spoke with V1 (Administrator) regarding obtaining
R1's medical records and V10 still has not received R1's medical records. V10 then explained that V10
received a call from the facility right before surveyor called V10 stating that R1's medical records were
ready for V10 to pick up at the facility after V10 has been waiting a month for R1's medical records.
On 01/16/23 at 2:18 pm, V3 (Medical Records Coordinator) stated that V3 has been the facility's Medical
Records coordinator at the facility for 2 years. V3 stated that when there is a request for a residents medical
record there is a medical record request form completed. V3 then explained once V3 receives the medical
records request form V3 gives the medical records request to V1 (Administrator) and V2 (Director of
Nursing, DON) for approval to release the residents medical record. When V3 was asked regarding the
timeframe in which a residents medical record request is released/given, V3 stated, It depends on when
they ask for the request. When V3 was asked regarding the facility policy for the timeframe to release a
residents medical record request V3 stated, I (V3) don't know the facility policy regarding giving the family a
medical records request. It takes about 1-2 days. V3 was asked regarding R1's medical record request and
V3 stated that V1 instructed V3 to do not release R1's medical records until the facility receives R1's death
certificate. V3 stated that V3 received R1's death certificate about three weeks ago and that V3 did not send
R1's family the medical records request. V3 stated that V3 was off for the holidays and that V1
(Administrator) covers for V3 when V3 is absent from work. V3 stated that V3 phoned V10 (R1's family) right
before speaking to surveyor to inform V10 that R1's medical records were ready to be picked up.
On 01/16/23 at 2:34 pm, V1 (Administrator) stated that V1 oversee V3 (Medical Records) at the facility. V1
explained that V3 is currently responsible for processing residents medical records request at the facility. V1
explained that for a residents medical record to be released there is a form
(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:
145767
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
145767
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paul House & Health Cr Ctr
3800 North California Avenue
Chicago, IL 60618
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)
F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
called authorization for release for medical records to be completed. V1 then explained once the release for
a residents medical record form is completed the form is given to V3 to be processed. When V1 was asked
regarding the timeframe to complete a residents medical records request once the release for residents
medical record form is completed and given to V3, V1 stated that the residents medical record request
should be complete as soon as possible and that a medical records request can take up to a week to
complete at the facility. When V1 was asked regarding R1's December 15, 2023, medical record request,
V1 stated that R1's medical record request has been pending for about one month. V1 stated that V1 is
responsible for covering medical records request in the absence of V3. V1 then stated, With the holidays
there was a mix up with issuing R1's medical records while V3 was absent from the facility. When V1 was
asked the importance of providing a request of a residents medical record, V1 explained that it is the
residents right to obtain the residents medical record at the facility.
The facility's document dated December 15, 2023, and titled Release of Information shows that R1's
medical records information is to be disclosed to V10 (R1's Family Member) requested on December 15,
2023.
R1's death certificate dated December 12, 2023, shows that R1's medical record was issued on December
22, 2023.
The facility's policy titled Residents Rights for People in Long-term Care Facilities documents, in part:
Participate in your own care: You have the right to all information about your medical condition and
treatment in a language that you understand . You may purchase a copy of part or all of your records at a
reasonable copy fee within two working days of your request.
The facility's undated policy titled Release of Information documents, in part: Procedure: . 5. Resident may
initiate a request to release such information contained in their medical records and charges to anyone they
wish. Such request will be honored only upon receipt of a written, signed, and dated request from the
residents or legal representative.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145767
If continuation sheet
Page 2 of 2
