Health inspection·August 29, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a nurse followed established procedures for documentation in a residents electronic medical record (EMR). This failure affected one resident (R1) out of three residents reviewed for quality of care. Residents Affected - Few Findings include: R1's face sheet shows R1 has diagnoses which includes but not limited to hyperlipidemia, schizoaffective disorder, primary generalized osteo arthritis, legal blindness, unspecified ptosis of bilateral eyelids, central corneal opacity right eye, gastritis unspecified without bleeding, insomnia, and dysphagia. R1's Brief Interview for Mental Status (BIMS), dated 08/21/24, shows R1 does not have a BIMS score, and indicates R1 has memory problems and is severely impaired. R1's progress note, dated 08/21/24 at 1:02 am, authored by V8 (Licensed Practical Nurse, LPN) documents, While making rounds at 11:30 pm noted resident with lethargy. Obtain vital signs (temperature)T 99.9, (pulse) P114, (respiration) R16, (blood pressure) B/P 115/63, (oxygen saturation) SPO2 89%. (R1's) physician made aware with order to send resident to local hospital ER (emergency room). Local ambulance called with (estimated time of arrival) ETA of 3 to 4 hours and suggested 911. 911 was called. Resident was transferred (transferred) to local hospital at 12:55 am. R1's progress note, dated 08/21/24 at 6:50 am, authored by V8 (LPN) documents, Resident was diverted to local hospital and (R1's) physician made aware. Follow up call was made to local hospital ER, this writer was told that nurses are giving report and to call back in an hour time. Endorse to in-coming nurse to follow up resident status. On 08/27/24 at 6:52 am, V8 (Licensed Practical Nurse, LPN) was asked regarding V8's progress note authored on 08/21/24 at 1:02 am that documented V8 sending R1 to the local hospital. V8 stated, I (V8) did not document that. I never worked on the second-floor or with that resident. I do not know that resident. I let (V9, LPN) use my access to get into the computer because she could not get in. Inever assessed that resident. When V8 was asked regarding the facility's policy and procedure for documenting in a residents electronic medical record, V8 stated, It is not professional practice to give another nurse access to document in a residents medical record with my credentials because I can be held liable for the assessment and implicated. I gave it to her (V9) because she needed to get into the computer and couldn't. On 08/27/24 at 7:05 am, V9 (LPN) was asked regarding the progress note documented with V8's electronic signature on 08/21/24 at 1:02 am. V9 stated, I used (V8's) electronic access to document in (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: 146198 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 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 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)