Health inspection·October 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report and investigate an allegation of misappropriation of property for one (R1) of three residents reviewed for misappropriation of resident property in a total sample of three residents. Findings include: R1 ' s Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating R1 is cognitively intact. R1's social service assessment, dated 9/11/2024, documents R1 has corrective lenses for vision. R1's progress note, dated 09/26/2024 at1:49 PM, documents, (R1) continues to insist the glasses was stolen from her room. Writer (V4) mentioned maybe she just misplaced the glasses. (R1) became very upset stating to writer (V4) 'I know what I'm talking about, someone took my glasses because they were from a designer. I purchased them at a glasses store'. On 10/08/2024 at 11:42 AM, R1 stated it has been over three weeks, and the facility has not done anything about her stolen eyeglasses. R1 stated she remembers that she placed her glasses on the bedside table the night before they were gone. R1 stated she thinks another resident from this floor took them, but she does not have any names she can think of. R1 stated the staff didn't call it stealing, and she doesn't know why not. R1 stated the glasses are designer frames and the eyeglasses frame color is blue with black stripes. R1 stated she thinks her glasses were stolen so whoever stole them can sell them and get money. R1 stated she looked everywhere in her closet and R1 stated her roommate also looked in her belongings and no glasses were found. R1 stated she informed everyone about her glasses being gone. R1 showed surveyor the eyeglasses' case which observed to be a designer brand case. On 10/08/2024 at 11:50 AM, V4 (Licensed Practical Nurse/LPN) stated R1 was claiming someone took her eyeglasses. V4 stated she did search R1's room, but the glasses weren't found. V4 stated R1 told her R1's glasses were blue and designer brand. V4 stated R1 did not mention any resident or staff names to her. V4 stated she notified V2 (Director of Nursing) so it could be investigated. On 10/08/2024 at 1:03 PM, V2 (Director of Nursing) stated when V1 (Administrator) was on vacation, V2 is responsible for covering his duties. V2 stated she did not complete a report to the State Agency because she was not aware R1 had reported the glasses stolen. V2 stated she denies any resident wandering in R1's floor, and she does not have any concerns any stealing is going on. (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 10/11/2024 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)