Inspection·May 9, 2025

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to procure proper written authorization to manage resident's trust funds for 2 residents (R1 and R4) out of 5 residents reviewed for financial management. This failure resulted in R1 displaying aggressive behavior due to lack of consent for the facility to manage personal trust fund, and R1 being hospitalized for aggressive behavior. Residents Affected - Few Findings include: 1. R1 is [AGE] years old, initially admitted in the facility on 07/19/2024. R1 medical diagnoses includes major depression, bipolar disorder, anxiety disorder and post-traumatic stress disorder. R1 is cognitively intact with Brief Interview for Mental Status (BIMS) score of 15, dated 04/03/2025. On 05/06/2025 at 1:15 PM, R1 can clearly express her thoughts within topic during conversation. R1stated the facility was asking her to sign paperwork, but she refused, and the facility forged her signature that will make her check go to the facility. R1 stated she refused to sign the paperwork because she can manage her own money. R1 stated when she called Social Security, she was informed the payee is now the facility, and a bank was added into it. R1 stated she was very agitated because of what happened. R1 stated R1 saw an envelope on V3 (Business Office Manager) that has R1's name. When she tried to get it, V3 covered it. R1 said, I was angry and called her a liar. They had me out to the hospital. Clinical notes, dated 04/17/2025 by V8 (Licensed Practical Nurse), documents per clinical staff, R1 was noted with physical aggression towards staff, with increase agitation and crying spells, and loud disruptive behavior. R1 was unable to be redirected per staff. On 05/07/2025 at 10:10 AM, V3 (Business Office Manager/BOM) stated it is not necessary, or there is no need for authorization coming from resident for the facility manage resident funds. V3 said, When Social Security got information that the resident resided in the facility, they deposit the funds to the facility. V3 stated in R1's case, there was no authorization coming from R1 for facility to manage her personal fund. V3 stated roughly 98% of residents do not have authorization. V3 stated there is a form called rep payee. V6 (Administrative Consultant), who was inside the room during conversation with V3, stated it means representative payee. V3 was asked to present representative payee or any authorization form R1 consented in favor of the facility to manage her personal fund. V3 presented a form titled Authorization and Agreement to Handle Resident Funds by V7 (Outside Vendor/Managing Resident Funds) on the line where resident needs to sign was left blank. Under the line on the right side was written refused to sign. 2. On 05/07/25 at 10:10 AM, V3 did not present R4's written authorization form. Per V3, R4 does not (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 5 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 05/09/2025 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)