Health inspection·January 8, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to maintain mechanical heating equipment, failed to ensure mechanical and electrical heating equipment were not exposed to poor environment conditions (leakage of fluid from ceiling due to water heater tank), failed to maintain at least 75 degrees Fahrenheit during cold temperature, and failed to monitor temperature in the building during cold temperatures. These failures have the potential to affect all 144 residents living in the facility. Findings include: On 1/7/2025 at 09:09 AM, V3 (Maintenance Director) stated, The boiler control system got wet last Friday (01/03/2025) that caused the problem with the heating equipment of the facility. (V9, Heating and Cooling Repair Company) came to the facility on Sunday (01/05/2025) for repair. The front part of the building facing east was too cold during those times. V3 handed a receipt from V9, dated 01/05/2025, stating: Front East Side too cold. Checked heating zones and functional. Checked boilers and reset thermostats. Rechecked cold areas and all heat on. V3 stated, The facility heating system has three steam boilers. One of the boilers control got burned because of the drip on it. V3 stated, The heating system was not able to increase the heat to 75, because the boiler was down. V3 stated he heard complaints that it was cold for R5 and R1, and that it affected the east area of the building on the 2nd floor. V3 said, But I think it was (room number). V3 was asked since it was identified those rooms on the 2nd floor east area were affected by the cold weather, why were those rooms temperature not monitored? V3 did not answer. On 1/7/2025 at 02:15 PM, V3 stated, There is no temperature log for the month of December. No temperature log were provided except the documents from 01/03/2025 to 01/06/2025. V3 stated from now on he will start to organize all necessary procedures, including temperature taking in areas of the facility. V3 was asked when was the last time V9 (Heating and Cooling Repair Company) came to maintain facility's heating system,and does V9 has a schedule to check or maintain heating equipment of the facility on a periodic basis? V3 replied, That is one of the problems since the old maintenance director there was no record of facility's heating system being checked or maintained. When asked if it will help when there is a scheduled maintenance on heating equipment to prevent possible problem? V3 replied, Oh yes, it will help if the facility has yearly maintenance checks. On 01/07/2025 at 10:08 AM, in the area where heating system was located, there were three large boilers. All three boilers have rust on many areas and dirt wa present all over the room. Upon looking up at the ceiling, multiple areas of liquid was dripping on the floor and onto the boilers. The middle boiler had the most liquid dripping directly. V3 stated, The [NAME] roof-like thing and plastic covers the plastic control circuits. Because that was the reason why one of the boilers broke when (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 3 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 01/08/2025 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)