ALL AMERICAN VLGE NRSG & RHB
For profit - Limited Liability company
144 Beds
Independent
Data: November 2025
Trust Grade
38/100
#315 of 665 in IL
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
All American Village Nursing & Rehabilitation in Chicago has a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #315 out of 665 facilities in Illinois places them in the top half, but their county rank of #100 out of 201 shows there are many local options that may be better. The facility is worsening, with issues increasing from 11 in 2024 to 14 in 2025. Staffing is a concern, rated at 1 out of 5 stars, although their turnover rate of 25% is better than the state average of 46%. Notably, there have been serious issues with food safety practices and water system management, including expired food items and a lack of plans to prevent Legionella bacteria growth, which could pose health risks to residents. On a positive note, there are no recorded fines, and their quality measures rating is excellent at 5 out of 5 stars, indicating some strengths in overall quality of care.
- Trust Score
- F
- In Illinois
- #315/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 25% annual turnover. Excellent stability, 23 points below Illinois's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Illinois facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 12 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Top 47%
Review needed
11 → 14 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 14 issues
The Good
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5-Star Quality Measures · Strong clinical quality outcomes
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Low Staff Turnover (25%) · Staff stability means consistent care
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Full Sprinkler Coverage · Fire safety systems throughout facility
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No fines on record
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Staff turnover is low (25%)
23 points below Illinois average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Illinois average (2.5)
Below average - review inspection findings carefully
The Ugly 32 deficiencies on record
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**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 reside...
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**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.
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 have written authorization. V3 stated R4's fund is being managed by the facility receiving physical checks instead of electronic checks, and R4 did not sign the authorization form yet.
Resident Personal Trust Fund Policy and Procedure, dated 05/15/2024, reads:
Residents/Guardians or Residents' Persons of Authority desiring to have a personal funds account must authorize service by signing an authorization form. This form will be maintained in their Business Office file.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish an environment that promotes resident sensi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish an environment that promotes resident sensitivity and safety and prevention of mistreatment for one resident (R3) out of four residents reviewed for abuse.
Findings include:
R3 is [AGE] years old, initially admitted in the facility on 10/08/2015. R3 medical diagnosis includes schizoaffective disorder, bipolar, psychosis.
Per Minimum data Set (MDS) assessment, dated 04/02/2025, R3 has a score of 12; R3 has moderate impairment of his cognition.
R4 is [AGE] years old, initially admitted in the facility on 07/12/2024. R4 medical diagnosis includes schizoaffective disorder, bipolar type, anxiety disorder, psychosis.
Per Minimum Data Set (MDS) assessment; dated 04/11/2025, R4 has a score of 7; R4 has severe impairment of his cognition.
Per clinical notes, R4 had multiple behavioral concern involving staff and other residents. R4 was given antipsychotic medication Haloperidol injection multiple times to manage behavior. Review of R4's notes for the month of March and April 2025, it documents as follows:
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Dated 04/24/2025 by V4 (Licensed Practical Nurse) documents, R4 agitated and yelling to himself.
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Dated 04/19/2025 by V9 (Licensed Practical Nurse) documents, R4 noted with increased aggression, screaming and pacing the hallway, unable to redirect.
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Dated 03/28/2025 by V10 (Licensed Practical Nurse) documents, R4 physically aggressive towards members of the staff during breakfast. R4 was sent to the hospital due to his behavior.
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Dated 03/17/2025 by V4 documents, R4 has increased in aggression towards the members of staff and peers during breakfast. He was observed screaming, yelling and tried to have a physical fight with a member of staff.
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Dated 03/09/2025 by V9 documents, R4 noted with increased agitation, screaming, singing very loud and attempted taking food off other resident's plates at lunch in the lobby. V13 (Former Social Service) document, R4 taking food from other residents.
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Dated 03/04/2025 by V12 (Former Director of Nursing) documents, R4 has behavior of snatching food off other residents' plates and tampering with the fire alarms.
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Dated 03/02/2025 by V4 documents, R4 was agitated towards peers during breakfast.
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Dated 03/02/2025 by V14 (Psychiatric Nurse Practitioner) documents, The staff reported that R4 continues to intermittently displays verbal aggression and agitation towards peers without provocation, remains in need of Haldol (antipsychotic medication) for agitation.
On 04/10/2025 per census history, R3 was transferred in the same room with R4.
On 04/30/2025, an abuse incident happened between R3 and R4. Incident document an allegation of abuse involving R3 and R4 was noted. Per V4 (Licensed Practical Nurse) clinical notes, dated 04/30/2025, R3 had physical incident with R4.
Facility's investigation includes interview log/written statement by facility staff, it documents as follows:
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R3 stated he was laying when R4 came at him. R3 stated, I didn't do nothing. I mean (R4) has never been like this. I am okay though, what's wrong with him?
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R4 unintelligible things was noted on R4's interview.
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V5 (Social Service Director) stated, I was walking the hall when I heard something and got to the room and found (R4) stripped and out of it. It was around 03:00 PM shift change. V2, Director of Nursing, stated, I was on the floor when I saw (V5 )run towards the room. I followed and we immediately intervened when we got to the room. V4 (Licensed Practical Nurse) stated, I saw everyone rush towards the room and (R4) came out naked, we redirected him, and he got dressed and was on close monitoring.
On 05/06/2025 at 1:40 PM, R3 was able to express his thoughts clearly within topic during conversation. R3 stated R4 tried to put up a fight. Then R4 started hitting him on the back of his head, also on his ribs. R3 was asked if he got injuries because he was hit by R4. R3 replied, yes, on my ribs. R3 lift his shirt showing his ribs. R3 said, I don't know if you can see any injury. I don't know what started it at all. We have been roommates for weeks or less than a month. I did not hit him back. I tried to push him away. R3 was asked if he feels safe? R3 replied, I feel safe, for now. R3 was asked what he means for now. R3 did not elaborate. R3 was asked how he feels if R4 is around. R3 did not answer.
On 05/07/2025 at 9:13 AM, V5 (Social Service Director) stated R4 has had behavioral problems in the past, including aggressive behavior towards staff and other residents. Per V5, R3 did not say R4 hit him. V5 stated R3's cognition is intact and able to describe what happened; R4 has severe impairment of his cognition. V5 was asked the reason why R3 was transferred in the same room with R4? V5 said, I do not know the reason why he was placed into the same room with (R4). V5 stated staff monitors residents, but incidents that happened between R3 and R4 happened fast. V5 stated placing himself to R3's situation, being with a person who have aggressive behavior, will make him feel indifferent. V5 was asked what are interventions placed by facility for R3 and R4 to prevent incident of abuse from happening? V5 reviewed R3's full care plan, then stated there is no care plan or intervention seen related to abuse prevention. V5 then reviewed R4's care plan and pointed to the care plan for behavioral symptoms, dated 03/28/2025. When R4 displays physical behavior directed towards others (staff) resulting to R4's involuntary hospitalization. On the care plan interventions, it documents R4 needs to be separated from other person as needed due to his behavior. V5 was asked why R3 brought into the same room with R4 since care plan intervention documents R4 needs separation as needed due to his behavior? V5 stated he does not know the answer. Another care plan intervention for R4's behavior was for social service to assess R4 for aggression. V5 stated, I think he (R4) was assessed. Per Aggression Risk Review, dated 04/30/2025, R4 was assessed to have physical aggression. Although R4 has multiple documentation of aggression, R4 was assessed without aggressive combative incidents. There was no aggression assessment done from the date of care plan intervention, dated 03/28/2025, to actual abuse incident when R4 hit R3 on 04/30/2025.
On 05/07/2025 at 09:41 AM, V1 (Administrator) stated during the incident, she was talking to V5 (Social Service Director). V1 stated R3 told her R4 hit him on his right shoulder. V1 stated incident happened quick. V1 said, It was so quick that next second (V5) said 'I had to go'. Next thing I know, it happened. It was really quick. V1 stated R3 and R4 room was placed near the nurse station for nursing staff to monitor. V1 was made aware the room was not close to nurse station. It is located near the elevator far from the nurse station. V1 stated, Is it not close to the nurse station? But they (R3 and R4) need to be monitored. V1 was asked why R3 was placed on the same room with R4? V1 stated, No, I don't know the background why they became roommates. V1 was asked if there were interventions in place to prevent incidents of abuse when R3 was transferred in the same room with R4? V1 stated, We usually go over those things in the meeting. V1 stated she wants to verify if R3 was transferred due to room change, which is facility-initiated or during readmission. V1 said, (R3) may be in the same room with (R4) not by facility-initiated room change. It may be due to direct re-admission from the hospital. Upon checking R3's record, transfer was initiated by facility due to bed change, not hospital readmission. V1 said, Oh, it was room change, not re-admission.
Abuse Prevention Program Policy and Procedure, dated 01/2025, reads:
This facility affirms the right of our residents to be free from abuse. This facility prohibits abuse; to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This will be done by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment.
Apr 2025
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed assert the right of the resident by searching a residents' room and pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed assert the right of the resident by searching a residents' room and personal property without the residents' knowledge and consent. This failure affects one (R33) resident in a total sample of 27 residents reviewed.
Findings include:
R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate.
R33's MDS/Minimum Data Set, dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired.
On 04/08/2025 at 11:32 AM, V8 (Certified Nursing Assistant/CNA) was sitting on R33's bed, and V8's right hand inside of R33's nightstand located adjacent to R33's bed. V9 (CNA) was sitting in a chair at the foot of R33's bed, with a water container placed on R33's bedside table. R33's closet was open, and R33's clothing was exposed. R33 wass not located inside of his room at this time. V8 stated he is inside of R33's room because he is taking his lunch break. V8 was asked why his hand was located inside of R33's nightstand. V8 stated he was only looking, and stated he did not take any of R33's items.
V9 stated this is her very first day working in the facility, and she is assigned to be trained by V8, and is shadowing V8's schedule. V9 stated R33's closet door was already open prior to V8 and V9 going inside of R33's room. V9 stated she was only drinking her water and sitting down waiting on further direction from V8.
V8 stated he is aware that he should not be inside of any of the residents' rooms without their knowledge and while the residents are not located in their rooms. V8 stated he is not assigned to care for R33 today. V8 stated going inside of R33's nightstand is a violation of R33's rights.
On 04/08/2025 at 11:53 AM, R33 was observed sitting in the dining room located on the second floor of the facility.
On 04/08/2025 at 11:47 AM, V3 (Licensed Practical Nurse/LPN) stated all staff members have a designated break area located on the fourth floor of the facility. V3 stated staff should go to that break room whenever they take their assigned lunch breaks.
On 04/10/2025 at 12:45 PM, V2 (Director of Nursing/DON) stated staff members should not be inside residents' rooms during their assigned breaks. V2 stated staff members should not be searching through residents' personal belongings without permission. V2 stated this is a violation of R33's resident rights.
Facility policy, dated 10/2024, titled Resident Rights Guideline documents, Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents' individuality. The facility protects and promotes the rights of the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed provide privacy and confidentiality of personal informat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed provide privacy and confidentiality of personal information for one (R33) resident reviewed in a total sample of 27.
Findings include:
R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate.
R33's MDS/Minimum Data Set, dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired.
On 04/08/2025 at 11:53 AM, R33 was sitting in the dining room located on the second floor of the facility. R33 was sitting in a wheelchair wearing a white hospital wristband on his right wrist, which displayed R33's full name, date of birth , age, and medical record number.
Record review of R33's electronic health record documents R33 was last admitted to the hospital on [DATE], and returned to the facility on [DATE].
On 04/08/2025 at 12:31 PM, V2 (Director of Nursing/DON) observed the white hospital wristband on R33's right wrist. V2 was made aware of R33's full name, date of birth , age, and medical record number being displayed for anyone to see. V2 stated the wristband was placed on R33 in the hospital, and it should have been removed once R33 was admitted back to the facility. V2 stated R33 should not still be wearing the hospital wristband with his private health record information displayed. V2 stated this is a violation of HIPAA/Health Insurance Portability and Accountability Act, and V2 will get some scissors to cut R33's wristband off.
Facility policy, undated, titled Health Information Management- Resident Information Privacy Protection documents, Policy: To assure that all resident-identifiable information maintained by the facility shall be confidential and disclosed only to authorized individuals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new PASARR screening for one (R79) resident reviewed for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new PASARR screening for one (R79) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 27.
Findings include:
R79's facesheet documents R79 was admitted to the facility on [DATE].
R79's PASARR Notice of SLP/Supportive Living Program Setting Appropriateness outcome letter, dated [DATE], documents an SLP setting is appropriate for R79.
R79's SLP Setting Appropriateness Outcome Explanation Notice documents, This SLP initial screen and SLP comprehensive assessment is good for up to 90 calendar days of the Notice Date listed on the Notice of SLP Setting Appropriateness Outcome If you do not go to a SLP setting within that time, you must have an updated SLP initial screen and SLP comprehensive assessment.
On [DATE] at 11:15 AM, V20 (Business Office Manager/BOM) stated she has been working at the facility for only 11 days, and is responsible for inputting resident information into the PASARR screening system when a resident is admitted to the facility. V20 stated whenever a residents' PASARR screening is about to expire, the facility needs to request a new screening to be completed. V20 stated she is unsure of R79's PASARR screening results for his living setting. V20 stated the facility is responsible for initiating R79's transition to a SLP. V20 stated the facility has to contact the screening agency to come to the facility and assess R79 to see if he is appropriate for the nursing home setting. V20 stated Social Services is also responsible for inputting resident screening information and ensuring that screening is performed and updated. V20 stated Social Services will also get a notification via email about appropriate resident living settings and a residents' need for transitioning to another setting.
On [DATE] at 11:28 AM, V22 (Social Services Director) stated he has been working at the facility for 5 months and is responsible for updating resident PASARR screenings. V22 stated he checks the screening agency system every other day, or when he has time to do so. V22 stated the screening agency system shows the list of residents who require updates to their screening. V22 stated this is how he is made aware of which screenings are expiring and needs an update. V22 stated he is not aware of R79's PASARR SLP screening having an expiration date. V22 stated based on the documentation, R79's PASARR SLP screening is expired because it is now past 90 days. V22 stated he has not received any email notification for R79's PASARR SLP screening expiring.
Facility policy, dated 12/2023, titled, Pre-admission Screening and Resident Review (PASRR) documents, IDPH (Illinois Department of Public Health) rules mandate that it is the transferring (not receiving) facility's responsibility to send the correct PASRR paperwork or make sure that it is located in the screening agency system.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new Level I screen for a resident with known mental illn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new Level I screen for a resident with known mental illness for one (R40) of five residents reviewed for Pre-admission Screening and Record Review (PASRR) in a total sample of 27.
Findings include:
R40's face sheet documents R40 was admitted to the facility on [DATE], with diagnoses not limited to: Hypertensive heart disease without heart failure, schizoaffective disorders, seizures, bipolar disorder, major depressive disorder, recurrent, unspecified, other obsessive-compulsive disorder.
R40's Interagency Certification of Screening Results OBRA (Omnibus Budget Reconciliation Act)-I Initial Screen, dated 06/02/2004, indicates R40 has reasonable basis for suspecting MI (mental illness).
R40's Minimum Data Set (MDS) Section I, dated 04/03/2025, indicates active diagnoses of depression and bipolar disease.
On 04/10/2025 at 9:46 AM, V1 (Administrator) was asked about level I pre-admission screening and resident review (PASRR) screening for R40, who was admitted to the facility with a diagnosis of a psychiatric mental health illness. V1 stated the facility does not have a PASRR screening for R40. V1 stated R40 was admitted to the facility many years ago, when PASRR screenings were not required. V1 informed the surveyor V1 asked V20 (Business )Office Manager) to request a PASRR screening yesterday (referring to date of 04/09/2025).
On 04/10/2025 at 9:51 AM, V20 (Business Office Manager) stated, The facility does not currently have a pre-admission screening and resident review (PASRR) for (R40) because he was admitted to the facility on [DATE]. At the time that (R40) was admitted to the facility, PASRR screenings were not required. The facility received an OBRA screening from a previous facility where (R40) resided, so the only thing we have is (R40's) OBRA screen. I submitted a request for an OBRA screen for (R40) yesterday. We have been doing a lot of cleaning up and auditing the charts for the residents who have been residing in the facility for a long time, prior to the PASRR being required. The PASRR screening became a requirement about 3 to 4 years ago. The PASRR screen for (R40) should have been done by now, but it fell through the cracks and the facility never requested a PASRR screening. I am new here and have only worked here for 13 days. I am trying to catch up with the documents that fell through the cracks. I am auditing the charts to make sure that the residents have PASRR screenings, as per the state requirement. (R40) has a mental illness.
Pre-admission Screening and Resident Review (PASRR) (revised 12/2023) states: In accordance with Federal and State of Illinois regulatory standards and recommended practices, this organization requires each resident to be screened for Level 1 prior to or shortly thereafter admission. The facility makes reasonable efforts to make sure the required screening documents are in the AP/PT system prior to admission or shortly after the time of the individual's arrival.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders by not monitoring a resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders by not monitoring a resident's stoma site (Ileostomy site) every shift for one resident (R70) out of 7 residents reviewed for nursing care in a total sample of 27 residents.
Findings include:
R70's face sheet documents R70 was admitted to the facility on [DATE], with diagnoses not limited to: Chronic obstructive pulmonary disease, unspecified, bipolar disorder, current episode depressed, severe, with psychotic features, and Ileostomy status.
Minimum Data Set Section (MDS) section C (dated 04/01/2025) documents R70 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R70's cognition is intact.
Care plan (dated 04/10/2025) documents R70 has an ostomy related to Ileostomy status.
R70's physician order (dated 04/10/2024) states: Monitor the Stoma Site (Ileostomy site) for any signs of infection or changes in skin issues every shift (day, evening, night). For any concerns notify medical doctor.
On 04/10/25 at 10:30 AM, R70 expressed having concerns with the nurses not providing ileostomy care as they should per the physician's order. R70 had a ostomy bag.
R70's Treatment Administration Record (TAR) documents in the month of April 2025, R70's stoma site was not being monitored by the nurses, as per the physician order. R70's Treatment Administration Record indicated R70's stoma was not monitored on 04/01/2025, 04/02/2025, 04/03/2025, 04/04/2025, 04/05/2025 (night shift), 04/06/2025 (day and night shift), 04/07/2025 (day and evening shift) and 04/08/2025 (evening and night shift).
On 04/09/2025 at 12:43 PM, V17 (Nurse Consultant) stated, In the physician orders for (R70), the nurses are to monitor the stoma site every shift for signs of infection and changes and skin issues. According to the treatment administration record (TAR), there are days that are missed by the nurses.
Facility policy regarding Colostomy/Ileostomy Care (undated) documents: The following information should be recorded in the resident's medical record:
1. The date and time the colostomy/ileostomy care was provided.
2. The name and title of the individual(s) who provided the colostomy/ileostomy care. 3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free from expired food for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free from expired food for one resident (R102) out of 7 residents reviewed for nutrition in a sample of 27 residents.
Findings include:
R102's face sheet documents R102 was admitted to the facility on [DATE], with diagnoses not limited to: Hypertensive heart disease without heart failure, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, lymphedema, not elsewhere classified, and gastro-esophageal reflux disease without esophagitis.
Minimum Data Set Section (MDS) section C (dated 04/02/2025) documents R102 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R102's cognition is intact.
R102's Care plan (dated 04/09/2025) documents R102 is on a therapeutic diet regular, with no added salt.
On 04/08/2025 at 12:11 PM, R102 stated, This morning for breakfast, I received a milk that was expired. The date of expiration on the milk carton is 04/07/2025. The milk was spoiled. I just want to bring this to your attention because they should be checking the dates on the milk before they serve spoiled milk to the residents. R102 showed the milk carton, and surveyor noted an expiration date of 04/07/2025. After the surveyor inspected the milk R102 received for breakfast, the milk carton was discarded.
On 04/09/2025 at 9:53 AM, V1 (Administrator) stated, The staff are supposed to check the dates on the milk carton before placing the milk on the tray before serving it to the residents. When the milk is expired, staff are to immediately discard the milk and replace it with a milk with the appropriate date that is not expired.
On 04/09/2025 at 10:15 AM, V10 (Dietary Manager) stated, I put the old milk in the refrigerator to the left side and the new milk to the right side. We checked the dates on the milk before the milk is served to the residents. Every day, before the milk carton is served, the dates on the carton are checked to make sure that the milk is not old. When the milk is expired, it is tossed out and not served to the residents.
Labeling and Dating Foods Policy (dated 2021) documents: To decrease the risk of food borne illness and to provide the highest quality, foods labeled with the date received, the date opened and the date by which the item should be discarded.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to monitor and review antibiotic use for three (R79, R81, and R102) residents reviewed for antibiotic stewardship in a total sample of 27.
Fi...
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Based on interview and record review, the facility failed to monitor and review antibiotic use for three (R79, R81, and R102) residents reviewed for antibiotic stewardship in a total sample of 27.
Findings include:
On 04/09/2025 at 2:53 PM, V6 (Infection Preventionist/IP/LPN) stated she has been the IP at the facility for approximately one month now. V6 stated she generated the antibiotic tracking/monitoring list today, with the help of other staff members. V6 stated this is the first time she has generated the tracking/monitoring list for residents on antibiotics. V6 stated prior to today, there was not a system in place to track and trend antibiotic use for residents in the facility. V6 stated she has been trying to clean up some things as much as she can since she's been working at the facility. V6 stated now that she is aware, she can now keep track of resident antibiotic use. V6 reviewed the antibiotic order report, dated 04/2025. V6 stated she is not sure why some residents are prescribed antibiotics without an end date. V6 stated she will follow up on this. V6 stated all antibiotics should have an end date, even if it is an ointment or eye drop. V6 stated if residents are continuously receiving antibiotics without an end date, then the residents could potentially develop a compromised immune system that will not respond to antibiotics any longer. V6 stated additional complications related to other infections could also arise.
The facility's antibiotic order report, dated 04/2025, documents the following:
*R79 has an order for antibiotic tobramycin-dexamethasone drops, suspension with start date 12/19/2024 and no end date.
R79 has an order for antibiotic ofloxacin drops, with start date 12/19/2024 and no end date.
R79 has an order for antibiotic moxifloxacin drops, with start date 03/31/2025 and no end date.
*R81 has an order for antibiotic neomycin-bacitracnzn-polymyxnb topical ointment, with start date 03/08/2025 and no end date.
*R102 has an order for antibiotic ciprofloxacin 500mg tablets, with start date 04/09/2025 and no end date.
Facility policy, dated 04/29/2024, titled Antibiotic Stewardship Program Guideline documents, The purpose of an antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance. The purpose of an antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. Tracking: The facility will monitor antibiotic use and outcomes from antibiotic use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to discard medication without an expiration date in a ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to discard medication without an expiration date in a cart serving 42 residents on the third floor; failed to follow pharmacy instructions on medication administration while administering an inhaler for one (R31) resident; failed to document medications as given for one (R55) resident; and failed to contact provider while administering late medications to one (R84) resident in a sample of 27.
Findings include:
1. On [DATE] at 10:10 AM, V3(Licensed Practical Nurse-LPN) residents eMAR (Electronic Medication Administration) profile showed red on R55's medication profile for medications: Furosemide 40 Mg, Finasteride 5mg, Lisinopril 5mg, Memantine 10mg. V3 stated she gave the medication earlier, but forgot to sign as given. V3 stated the nurse administering medications should sign as soon as it is given to prevent medication error because another nurse might give the resident medication thinking it was not given, and it can also confuse the nurse giving the medication and not know if she/he gave the resident medications. V3 stated this can affect the resident if given medications double. V3 stated signing the medication as given prevents confusion and medication error.
2. On [DATE] at 10:20 AM, V4 (Licensed Practical Nurse-LPN) was administering Symbicort inhaler-two puffs to R31 back-to-back, and did not wait between puffs. V4 read the instructions on the medication label that documented, wait 30-60 seconds between puffs. V4 stated she waited two seconds before giving the second puff, and stated she should have waited between puffs as noted on the medication instructions to let the medication get absorbed properly in R31's body, so R31 can get the full benefits of the medication.
3. [DATE] at 11:00 AM, V5 (Licensed Practical Nurse-LPN) was administering medications to R84: Biktavy 200mg oral, Olanzapine 200mg oral, Folic Acid 1 tablet oral, Amantadine 100mg oral, Vit B-1(Thiamine) one tablet. V5 stated R84's medications were being administered late because R84 refused to wake up this morning. V5 stated medications should be given on time so that the resident can have therapeutic levels to promote management of their illnesses. V5 stated he should have notified the doctor when R84 refused his medications so that new orders can be given, or new administrations times can be given.
4. On [DATE], at 10:45 AM, 3rd floor medication cart and medication room reviewed with V11(LPN), and V2 (Director of Nursing).
Observed in the cart:
-A bottle of Ferrous Sulfate with open date of [DATE] written on the bottle. No expiration date was observed on the bottle.
V2 stated medications without expiration dates should be taken out of the medication cart because it is not known if they are expired, and might not be therapeutic if given to the residents and can cause bad side effects.
On [DATE] at 12:00 PM, V2(Director of Nursing) stated if a resident refuses medication, the nurse is supposed to notify the doctor, so the doctor can give orders and/or adjust the medications time, so that the resident can maintain therapeutic levels. V2 further stated nurses should read the instructions by pharmacy on the inhalers so that they can administer the medications as instructed on the medications label, so that the medication can be therapeutic to the resident.
Medication Administration Policy dated [DATE] documents:
-Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise.
-Medications shall be recorded on the MAR (Medication Administration Record) promptly after each administration by the individual who administered the drug.
-Clarifications and/or questions related to administering medications will be directed to the next highest authority in the nursing service, and if needed the attending physician or pharmacist.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a functioning call light system for eleven (R14, R22, R34, R47, R59, R64, R112, R118, R119, R133, R139) residents of ...
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Based on observation, interview, and record review, the facility failed to provide a functioning call light system for eleven (R14, R22, R34, R47, R59, R64, R112, R118, R119, R133, R139) residents of 27 reviewed for call light.
Findings include:
On 4/8/25 at 12:55 PM, R133 was asked to activate the call light. The light bulb above R133's door did not light up, and there was no audible sound heard.
On 4/8/25 at 12:58 PM, V18 (Certified Nursing Assistant) stated, There is a call light in each resident room. When it is pulled, it should light above the resident's door, and you should hear a sound. It also lights up at the nursing station panel. The call light is for emergency purposes; for the assistance of the resident. V18 pull the call lights in three resident rooms. Writer verified with V18 that no light came on over the door of the resident rooms. There was no audible sound heard, and the panel at the nursing station did not light up.
On 4/8/25 at 1:10 PM, V2 (Director of Nursing) stated, The purpose of the call light is so the patient can get assistance when needed, to accommodate the patient's needs. If the resident feels sick, they can get assistance. The call light is kept in reach for emergencies and non-emergency purposes. If the call light system is not operating, then the patient cannot call to get help. I was not aware the system is not working. There must be a glitch in the system. V2 pulled the call lights in (3 resident rooms). No light came on over the door of the resident rooms, and no audible sound was heard when the call light system was activated from each room.
On 4/8/25 at 1:22 PM, the call light system was activated in (resident room). The light over the door did not light up, and no audible sound was heard.
On 4/8/25 at 1:32 PM, the call light system was activated in (resident room). The light over the door and the nursing station panel lit up, however, no audible sound was heard.
On 4/8/25 at 1:40 PM, V19 (Certified Nursing Assistant) stated, Somebody was here last week looking at the call light system. We noticed there were no lights coming on and there was no sound. Currently there still is no sound from the system. The purpose of the call light system is if the resident gets sick and needs assistance. The CNAs (Certified Nursing Assistants) round hourly.
On 4/8/25 at 1:51 PM, V5 (Licensed Practical Nurse) stated, Last week they were working on the system. We only saw the light on, with no audible sound. The purpose of the call light system is if someone needs help, we assist. We have to go quick to answer the call light.
On 4/9/25 at 9:48 AM, V1 (Administrator) stated, My expectation is that staff are to do continuous check-ins in those areas identified with call light issues, and immediately notify maintenance in order to resolve the issue.
Facility Call Light policy, 5/2024, documents: Equipment: Functioning call light.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food is labeled, dated, and discarded after us...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food is labeled, dated, and discarded after use by date/expiration date and failed to ensure reach-in refrigerator temperature, walk in refrigerator temperature and walk-in freezer temperatures were monitored 2 times per day. These failures have the potential to affect 138 residents living in the facility.
The findings include:
On 04/08/2025 at 9:22 AM, the reach-in refrigerator was inspected, and the following food items were found inside the refrigerator:
*A container of nacho jalapeno peppers (1 gallon) with an open date of 02/08/25, and expiration date of 03/20/2025. V10, Dietary Service Director, said it should have been discarded.
*A container of giardiniera mild pepper mix (1 gallon) with no open date and expiration date of 10/08/2025.
*A container of sweet relish (1 gallon) marked with an open date of 04/07/2025, and no use by date.
*A jar of creamy peanut butter (5lb) with no open date and the use by date was not readable. *A container of red western dressing (1 gallon) with an open date of 04/06/2025, and the use by date was not readable.
*A container of silver source salad dressing (1 gallon) with an open date of 04/07/2025, and no use by date.
*A container of yellow mustard (1 gallon) with an open date of 04/07/2025, and no use by date.
*A jar of grape jelly (4 lb.) with no open date and no use by date.
*A jar of red [NAME] (24 oz.) with the open date and the use by date smeared and not readable.
Inspection of the dry foods/spice pantry was conducted with V10 (Dietary Service Director). The following food items were found:
*A container of Cajun Chef Louisiana Hot Sauce (1 gallon) with the open date of 03/25/2025, and no use by date.
*A container of Liquid Smoke Concentrated Sensory Hickory Sauce (1 gallon) with the open date of 02/18/2025, and no use by date.
*A bottle of [NAME] Vinegar (1 gallon) with the opened date of 02/11/2025, and no use by date. *A bottle of Liquid Smoke Concentrated Sensory Hickory Sauce (1 gallon) with an open date of 10/02/2024, and no use by date.
*A container of Black Pepper Ground (5 lbs.) with an open date of 03/25/2025, and no use by date.
*A container of Parsley Flakes (1 lb.) with the open date of 10/29/2024, and no use by date.
*A container of Light Chili Powder (80 oz.) with the open date of 09/03/2024, and no use by date.
*A container of Italian Seasoning (2 lbs.) with the open date of 02/18/2025, and no use by date.
*A container of Ground Nutmeg (16 oz.) with the open date of 03/18/2025, and no use by date.
Inspection of the reach-in refrigerator temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025.
Inspection of the walk-in refrigerator temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025.
Inspection of the walk-in freezer temperature logs for the month of April 2025 documented no entries on evening temperature on days 04/01/2025 to 04/08/2025. The temperature log had no entries for the morning temperature for the date of 04/09/2025.
On 04/08/2025 at 10:21 AM, V10 stated the cooks check the temperatures of the refrigerators and the freezers once per day, in the morning at the start of shift. V10 stated the cook documents the temperatures on the log only for the morning temperatures. V10 stated the cooks should be checking the temperatures 3 times per day, and not only once per day.
Labeling and Dating Foods Policy (dated 2021) states: To decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded.
Refrigerated Foods Policy (revised 2017) states: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by.
Storage of Refrigerated Foods Policy (revised 2017) states: Air temperature inside the refrigerator is checked and recorded twice daily. The reading on both the external and internal thermometers is recorded.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to implement a plan to prevent Legionella (a bacteria that can cause a serious type of pneumonia/lung infection) growth in the f...
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Based on observation, interview, and record review, the facility failed to implement a plan to prevent Legionella (a bacteria that can cause a serious type of pneumonia/lung infection) growth in the facility's water system. This failure has the potential to affect all 137 residents residing in the facility.
Findings include:
On 04/08/2025 at 1:56 PM, V21 (Maintenance Director/Housekeeping Director) stated he has been working at the facility for approximately 5 months. V21 stated he does not have a plan in place to check the facility's water system for Legionella. V21 stated he does not have any documentation to show the facility has a plan in place to prevent Legionella in the facility. V21 stated he has been searching, and is unable to find any previous documentation to show the facility's water system has been tested for Legionella. V21 stated at his previous employment, he implemented Legionella water testing, but has not implemented Legionella testing and prevention at the facility.
Facility census, dated 04/08/2025, documents a total of 137 residents reside in the facility.
Facility policy, dated 2023, titled Prevention of Legionella and Other Waterborne Pathogen Outbreak documents, It is the policy of this facility to reduce Legionella Risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease and other Waterborne Pathogens. Legionella can grow in parts of building water systems that are continually wet Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program.
To reduce cases of Legionnaires' disease in health care facilities, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare certified healthcare facilities must develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The directive has an immediate effective date. (https://www.ashrae.org/about/news/2017/cms-issues-directive-requiring-medicare-certified-healthcare-facilities-to-implement-and-maintain-legionella-prevention-policies)Legionella, the bacterium that causes Legionnaires' disease, .Legionella can pose a health risk when it gets into building water systems. Legionella first must grow (increase in numbers). Then it has to spread through small water droplets (aerosolization) that people can breathe in. (https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html)
Seven key elements of a Legionella water management program are to: Establish a water management program team, describe the building water systems using text and flow diagrams; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation) and document and communicate all the activities. (https://www.cdc.gov/legionella/wmp/overview.html)
Jan 2025
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**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 ensu...
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**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 the control panel got wet. V3 then showed the old control circuit located inside a rectangular shaped container that was damaged by dripping liquid on the ceiling. V3 stated the dripping water was coming from the water heater tank located on the first floor directly on top of the three boilers. On the 1st floor, inside the room where water heater tank was located, V3 pointed to the tank that cause ldiquid dripping on the boiler of the water heater system of the facility. V3 stated, Look at the bottom of the heater; it is all rotted. Water heater tank bottom was full of rust and liquid coming out of the tank to the floor continuously. The water heater tank has a written date of 2/23/12. V3 stated that was when they installed the water heater.
On 1/07/2025 at 10:26 AM, V2 (Director of Nursing) stated, On 1/02/2025, a nurse (V5, Licensed Practical Nurse) called me and said that the floor was cold. V2 stated she remembered one of the nurses needed to move the resident away from the window, and additional blankets were given. V2 identified the resident as R1.
On 01/07/2025 at 11:40 AM, R2 stated there are nights that it gets cold because the thermostat was at medium heat. R2 stated, I need 1 more blanket or 2 blankets because it feels cold. I wrapped one and the other one on top me.
On 01/07/2025 at 11:51 AM ,R1 stated, It was too cold; very cold some days. The heat only started yesterday (01/06/2025). There was no heat for one week. A bunch of air just comes out without heat (pointing at the radiator). R1 stated facility staff told her they have to knock the air out. R1 stated, I need two comforters, one was not enough because it was very cold. The right side of the body was aching because it was cold. R1 said facility staff told her she could sleep on her roommate's (R5's) bed because it was very cold.
On 01/07/2025 at 12:01 PM, V8 (Certified Nursing Assistant) stated last week they had a problem with the heater, and she worked last Friday. V8 said, It is warmer today than last Friday.
On 01/07/2025 at 12:21 PM, R3 stated, Days ago, I was using 2 blankets but still it did not help. It was so cold that 2 blankets were not enough. R4 stated she even slept with her coats on, and it lasted for 5 days, I did it because it was really cold. R3 and R4 are roommates.
On 01/07/2025 at 12:47 AM, V7 (Nurse Consultant) stated she became aware on 01/03/2025 about the problem on the heating system in the facility. V7 stated V3 told her they had an issue with the boiler malfunction. V7 stated she was not aware that on 01/02/2025, V2 (Director of Nursing) was informed by a nurse (V5 / Licensed Practical Nurse) about the problem. V7 stated V1 (Administrator) knew about the problem, but there was no communication between V1 and her. V7 stated after knowing about the problem, she tried to address the problem.
Facility's temperature log only covers dates from 01/03/2025 to 01/06/2025, and does not cover all hours indicated on the form. No temperature log was done on 01/02/2025 when V5 (Licensed Practical Nurse) informed V2 (Director of Nursing) that the floor where R1 was located was cold, and R1 was transferred into another bed away from the window and was given multiple blankets due to being cold.
V9 (Heating and Cooling Repair Company) provided the receipts documenting multiple repairs from 01/02/2025 to 01/06/2025.
Extreme Weather Temperature Policy with no date, reads:
To assure all departments assist in implementing appropriate interventions to maintain resident comfort during severe exterior temperature changes which may affect interior environment. Heating systems will be inspected, maintained, and repaired in accordance with the prevention maintenance schedule. The Maintenance Director will advise the administration of any serious malfunctions or need for repairs/replacements beyond approved budget. During extreme weather periods maintenance personnel shall take daily room temperature readings, in the dining areas, lounges and sampling of resident room on each floor or unit. In the event there are known malfunctions of temperature control equipment in those specific rooms or areas, they will monitor daily by maintenance and temperatures reported to administration daily until extreme weather or equipment problem resolves.
Oct 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to perform background check searches on the six offender Website links on the State Health Care Worker registry, and failed to ensure the init...
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Based on interview and record review, the facility failed to perform background check searches on the six offender Website links on the State Health Care Worker registry, and failed to ensure the initiation date of background checking were done prior to a new employee starting a work schedule. These failures have the potential to affect all the residents at the facility.
Findings include:
The (undated and untitled) facility provided document indicated V9 (Housekeeping/Laundry/Maintenance Supervisor) was hired on 09/26/24, V19 (Certified Nursing Assistant - CNA) was hired on 09/23/24, V20 (CNA) was hired on 09/23/24, and V22 (Certified Nursing Assistant) was hired on 10/09/24.
The (undated and untitled) facility provided document indicated V9 works all floors and started working 09/30/24, V19 and V20 work on 2nd floor and started working on 10/05/24, and V22 works on 2nd floor and started working on 10/09/24.
On 10/16/2024 at 10:01am, V4 (Business Office Manager) stated, It is required of the State Health Care Facilities to run the Health Care Worker Registries prior to hire to ensure who we bring into the facility to work are properly screened for the safety of our residents and other staff; to prevent potential abuse.
On 10/16/2024 from 10:13am - 10:37am, during the review of V9, V19, V20, and V22 personnel files, V4 stated, I checked their Illinois Sex Offender, Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive, and Health and Human Services Office of Inspector General registries yesterday (10/15/24) because I know you will look for these. I am under the impression once they are eligible at the State Health Care Worker Registry, it is okay to hire them without checking the other 6 registries. This surveyor also pointed out to V4 that dates were missing for the initiation of the background checking. V4 stated, There is really no assurance when I checked their background because there is no date indicated on the sheets.
On 10/16/2024 at 2:52pm, V1 (Administrator) stated, The main purpose of checking the State Health Care Worker Registry and to do searches on the other six registry links is to make sure the staff we hire do not have a background, like we cannot hire people who have records. Because if you hire a sex offenders or thieves, these people can put residents and staff in jeopardy. It is for the safety of the residents and staff. I expect (V4) to run backgrounds before the staff starts working to make sure that we are hiring appropriate people to work in nursing home.
Review of V9's personnel file has no date for the initiation of that background checking. Of note, the Illinois Sex Offender, National Sex Offender registries, and Health and Human Services Office of Inspector General registries were done on 10/15/24; and the Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive searches were not performed.
Review of V19's personnel file has no date for the initiation of that background checking. Of note, the Illinois Sex Offender, National Sex Offender registries, and Health and Human Services Office of Inspector General registries searches were performed on 10/15/24; and the Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive searches were not performed.
Review of personnel V20's file has no date for the initiation of that background checking. Of note, the Illinois Sex Offender, National Sex Offender registries, and Health and Human Services Office of Inspector General registries searches were performed on 10/15/24; and the Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive searches were not performed.
Review of V22's personnel file has no date for the initiation of that background checking. Of note, the Illinois Sex Offender, National Sex Offender registries, and Health and Human Services Office of Inspector General registries searches were performed on 10/15/24; and the Department of Corrections Sex Offender, Department of Corrections Inmate Search, Department of Corrections Wanted Fugitive searches were not performed.
The (2/2017) Abuse prevention program documented, Policy. This facility affirms the right of our resident to be free form abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: conducting pre-employment screening of employees. Procedures. I. Pre-employment Screening of Potential Employees. This facility will not knowingly employ any individual convicted by a court of law of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. This facility will not knowingly employ any staff convicted of any crimes listed in the State Health Care Worker Background Check Act or with findings of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property listed in the on the State healthcare Worker Registry. Prior to new employee starting a work schedule, this facility will: Check the State Health Care Worker Registry on any individual being hired for prior reports of abuse, neglect or misappropriation of resident property, and the six offender Website links on the Registry.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**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 propert...
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**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.
On 10/08/2024 at 1:38 PM, V6 (Certified Nursing Assistant) stated he has seen R1 with glasses, but he cannot remember which color or brand they are. V6 stated this is the first time he is hearing about R1 missing her eyeglasses. V6 stated if there are any allegations from a resident that they have had something stolen, he would search for it and take the allegation to his supervisor, the Director of Nursing. V6 stated there needs to be an investigation whether he thought it was true or not. V6 stated R1 is not one to complain very much, and he stated R1 is not really a troublemaker. V6 stated any type of abuse or misappropriation of property he would report it to V1, because V1 is the Abuse Coordinator.
On 10/08/2024 at 2:11 PM, V1 (Administrator) stated R1's allegation that someone stole her eyeglasses should have been reported as a misappropriation of property. V1 stated, If it was me, I would have done a thorough investigation. An investigation is done, whether it was founded or not, to determine the outcome. V1 stated the difference between a facility incident report form and a grievance form, is that a grievance form is a superficial approach addressing the concern.
Facility reported incidents dated June 2024 through September 2024 were reviewed, and do not document a report was submitted to the State Agency for an allegation related to misappropriation of property for R1.
On 10/09/2024, via email, V1 notified surveyor he has made an initial facility incident report on 10/08/2024, for R1's allegation of stolen eyeglasses.
Facility document not dated, titled Abuse Prevention Policy documents, Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
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 ...
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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.
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 (R1's) chart because I could not get into the computer system. V9 was asked regarding the facility's policy and procedure for documenting in a residents electronic medical record. V9 stated, It is not professional practice but, I could not get into the computer, so I asked (V8). I called (V2, Director of Nursing/DON) and made her (V2) aware that I had to use (V8's) access and that I could not get into the computer system.
On 08/27/24 at 11:26 am, V2 (Director of Nursing, DON) stated V2 became aware of V9 documenting in R1's medical record with V8's access the day after (08/22/24) R1 was sent to the local hospital, after V2 reviewed R1's medical record. V2 denied V9 informing V2 that V9 documented in R1's medical record with V8's medical record access. V2 stated V2 was reviewing R1's documentation for 08/21/24 and with V8's authored progress note, and was aware V8 did not author the progress notes on 08/21/24, due to V8 never working on the second floor or with R1. V2 stated, Nurses should not be sharing computer access. The nurse caring for the resident should be documenting under their own access and signature. If anything happens to the resident, then the nurse who access was shared will be held accountable. The nurse should have called me (V2) to reset her password. If I am not available then the Assistant Director of Nursing (ADON) should have been called. Nurses are educated regarding not sharing their access (passwords) upon hire to the facility.
The facility's policy, dated 2006 and titled Charting and Documentation, documents, Policy Statement: All services provided to the resident, or any changes in the residents medical or mental condition, shall be documented in the residents medical record. Policies Interpretation and implementation: 2. Entries may only be recorded in the resident's clinical record by licensed personnel . in accordance with state law and facility policy . 4. Information documented in the residents clinical record is confidential and may only be released in accordance with state law and facility policy.
The facility's policy, dated March 2014 and titled Health Information Management- Resident Information Privacy Protection, documents, Policy: To assure that all resident-identifiable information maintained by the facility shall be confidential and disclosed only to authorized individuals. Policy Specifications: 5. Resident Care: a.) only health care professionals directly involved in the care of an individual resident will have access to that resident's clinical record.
The facility's job description titled Charge Staff Nurse documents, Position Purpose: Provide direct nursing care to the residents, and to supervise nursing activities performed by nursing assistants. Administrative Functions: 2. Ensure that all written policies and procedures that govern day-to-day functions of the nursing department are followed. 3. Ensure that the Nursing Service Procedures Manual is followed in rendering nursing care . 6. Perform administrative duties such as completing medical forms, reports, evaluations, charting, etc. as necessary . Charting and Documentation: 2. Chart all accidents or incidents involving the resident. Follow established procedures . 4. Chart nurses' notes in an informative and objective manner that reflects the care provided to the resident, as well as the resident's response to the care. 5. Complete and file required record keeping forms or charts upon the resident's admission, transfer, and/or discharge . 11. Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures.
Aug 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep pests out of the facility. This deficient practice has the potential to af...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep pests out of the facility. This deficient practice has the potential to affect all 138 residents residing at the facility.
Findings include:
On 08/04/24 at 9:43 AM, R9 was sitting on the bed in R9's room. R9's room appeared clean. No garbage or debris was on the floor. R9 stated R9 has been at the facility for a couple of weeks and said, I've seen mice in my room since I've been here. I see them at night and during the day. R9 stated sometimes when R9 is taking a shower, R9 sees mice in the shower room, and R9 has also seen mice in the unit day room. R9 stated, No one has asked me if I've seen mice in my room, and other residents have also seen the same mice I have in the shower and in the day room, so I thought it's part of the norm here. I didn't think to tell anyone. I assumed they already knew it was a problem. R9 stated seeing the mice make him squeamish and said, I don't want mice in the same space that I'm living in. R9 stated he's never seen any staff from a pest control company in R9's room.
On 08/04/24 at 9:45 AM, R9 a large gray plastic container on the floor of R9's room was moved away from the wall. Dark brown/black small rice shaped pellets were along floor near the baseboards.
On 08/04/24 at 9:58 AM, V5 (Housekeeper) observed the pellets on the floor in R9's room along the baseboards and stated, Those are mouse droppings.
On 08/04/24 at 9:59 AM, V5 stated there is a sticky mouse trap on the other side of R9's room by the sink next to R10's bed. V5 pointed to the white sticky pad (glue board) in the corner under the sink in R9 and R10's room. The white glue board was covered in light brown elongated, oval shaped bodied insects. Some of the insects were alive because their antennas were moving, some of the insects appeared dead. V5 viewed the insects and stated, Those are roaches. There are 11 of them on the sticky mouse trap.
On 08/04/24 at 10:38 AM, V7 (Licensed Practical Nurse) stated V7 usually works the 11-7 shift and has seen mice in the facility. V7 stated V7 saw one or two mice two weeks ago, and informed V12 (Maintenance Director) and pest control was called. V7 stated V7 sees the pest control company inspecting the hallways and unit dining room. V7 stated V7 does not see them going into resident rooms.
On 08/04/24 at 10:28 AM, R5 stated, I have mice in my room. I see and hear them. R5 stated the Housekeeping staff came to clean R5's room one to two weeks ago and they found a lot of mouse droppings behind R5's bed and refrigerator. R5 stated Housekeeping has cleaned up the mouse droppings already. R5 stated R5 is not sure if the mice are still coming into R5's room, but R5 thinks they might still be around. R5 stated R5 has never seen anyone from the pest control company in R5's room.
On 08/04/24 at 10:30 AM, there were a lot of R5's personal items on the floor of R5's room such as clothing and shoes, and the drawers in R5's nightstand table were open and full of clothing and other personal items.
On 08/04/24 at 10:31 AM, small black rice shaped pellets were all along the baseboard in R5's room underneath the window. Many small black rice shaped pellets were seen in R5's bottom drawer of R5's nightstand table with a very small amount of urine in the same area.
On 08/04/24 at 10:32 AM, V5 (Housekeeper) observed the small black rice shaped pellets in R5's nightstand draw and on floor along baseboards and said, Those are mouse droppings.
On 08/04/24 at 11:00 AM, V14 (Housekeeper) stated last week V14 saw a mouse in R8's room, and V14 put down a sticky mouse trap (glue board) in R8's room to try to catch the mouse. V14 pointed to a glue board on the floor of R8's room near the baseboards to the side of R8's nightstand. Two light brown elongated, oval shaped bodied insects with antennas and small black rice shaped pellets were stuck to the glue board. V14 stated, Those are roaches and that looks like mouse droppings.
On 08/04/24 at 11:05 AM, R8 stated R8 has been living in the facility for about 6 months and Housekeeping has caught at least five mice in R8's room. R8 said, I've seen more than 5 mice, but 5 is the only ones they've caught so far. I don't know where the mice are coming from. I don't store any food in my room and keep it clean, but they are still around. I've never seen anyone from a pest control company in my room. The only thing the facility does is set up those sticky traps. At one point I had three sticky traps set up in my room, with two live mice caught in the sticky traps at the same time. It's gross. I shouldn't have to live like this. There is no game plan to tackle the problem here. They just keep doing the same thing, putting down the sticky traps. It's not working.
On 08/04/24 at 11:27 AM, V12 (Maintenance Director) stated it is important for the facility to provide a clean, rodent free environment for the residents because rodents can carry diseases and cause cross contamination of disease. V12 stated this is where the residents live and no one wants to live in a place full of rodents. V12 stated the facility has a pest control company that comes once a week for maintenance and monitoring of rodents/insects/pests. V12 stated the pest control company monitors and treats the common areas such as lobby, kitchen, laundry, boiler rooms and unit hallways, unit day room and the communal bathrooms/showers. V12 stated the pest control company does not go into a specific resident's room unless V12 tells them that a specific room has seen rodent or pest activity. V12 stated finding mouse droppings or holes around the room or debris in a pile indicate mouse activity and that likely places to see rodent droppings are near the radiators, or along the baseboards, and/or behind furniture. If the housekeeping staff sees any evidence of rodent activity they put down glue boards in that resident's room right away and notify the Pest Control Company who comes in right away even if they had already been to the facility that week. V12 stated the purpose of the glue boards is to catch the mice by causing them to stick to the board. V12 stated roaches also sometimes get stuck to them as well. V12 said, If you are seeing rodent droppings that means, there is rodent activity in that area. V12 stated V12 was notified 1-2 weeks ago that the Housekeeper found mouse droppings in R5's room. V12 stated the Housekeeper did a deep clean of R5's room and put down glue boards. V12 stated V12 did notify the Pest Control Company about increase in mice activity on 07/25/24, but did not tell them the specific room the mouse droppings were found or ask them to go into the room to set up mouse traps. V12 stated, Maybe I should have in hindsight.
On 08/04/24 at 3:22 PM, V1 (Administrator) stated the facility contracts with a pest control program who comes to the facility weekly and more often as needed. Whenever there are any concerns about pest, rodents, roaches or insects they are contacted and asked to treat the specific area including resident rooms with increased activity. The pest control company can put down other kind of traps other than the glue boards. V1 stated when pest control documents on their service reports which specific rooms they go in to treat. V1 stated if it is not documented on the form, then it was not done. V1 stated on 07/25/24, the pest control company did not go into any resident rooms. V1 said, If you are seeing mouse droppings and roaches then that means our current treatment plan is not working.
On 08/05/24 at 10:45 AM, via phone interview V18 (General Manager of pest control company) stated, When the pest control technician is on site, they touch base with the Maintenance Director or Administrator to find out if there have been any rodent or insect sightings. Unless the technician is told about a specific area, they would do the regular service check, which includes the common areas, not individual rooms. The pest control technicians would only go into a resident's room upon request. We are dependent on the facility to tell us that information. Finding mouse droppings is a sign that mice are present and roach activity is based on if live roaches are found. Glue boards are used to catch mice and sometimes that is effective in catching a mouse, but there are also additional things the pest control technician can do, such as using units containing poison and a mouse snap trap. If we were called into a room because there was mouse activity and we saw that the glue board was already down, then we would put into place the other two interventions. We would try a new intervention rather than just continuing with the glue boards. If the pest control technician went into a room to treat for rodent/insects they would indicate that on the service report, so if there is no room listed on the service report, then that means we did not go into that room because the facility did not ask us to or alert us that there was a problem in that area.
Grievance Binder reviewed from 06/08/24 to 08/02/24 with concerns related to the above allegation.
1.)
07/02/24, 10:00 AM, documents in part, R11 claims that there are mice and cock roaches in the facility and Pest Control came on 07/03/24, no activity found.
2.)
07/24/24, 10:00 AM, documents in part, R5 concern about mice in the building. Maintenance made aware and Pest Control came on 07/25/24, no findings.
Sentry Service Inspection Reports, dated from 05/01/24 to - 08/01/24, with area inspected included dining rooms, main kitchen area, laundry room, lobby, vending machine area, locker room and restrooms (2nd-4th floors). No specific rooms listed as being treated for rodent or pests or insects from 05/01/24-08/01/24 based on inspection reports.
Facility policy titled Guidelines for Pest Control, dated 11/01/23, documents the facility maintains an effective pest control company to remain free of pests and rodents.
Mar 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were two medication errors out of 27 medication opportunities,...
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Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were two medication errors out of 27 medication opportunities, resulting in a 7.41% medication error rate and affected two residents (R1, and R47) observed for medication pass.
Findings include:
1. R47's face sheet documents R47 has a diagnosis which include but are not limited to: schizophrenia, and unspecified psychosis not due to a substance or known physiological condition.
R47's Physician Order Sheet (POS) order date 02/07/24 through 03/07/24 shows R47 has an order for Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) orally by mouth every day. Diagnosis: Other schizophrenia.
R47's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R47 with a score of 15, which indicates that R47 is cognitively intact.
On 03/05/24 at 8:26 am, V16 (Licensed Practical Nurse, LPN) was observed on the second floor at the second-floor medication cart. V16 prepareed and counted 10 pills total that were administered to R47. V16 stated, Abilify (referring to Aripiprazole) is not here. I have to reorder it. Upon surveyor reconciling R47's medication for medications that were ordered for administration and medications that were observed as administered and documented by V16, the following medication error was identified:
- Missed Medication: Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) by mouth every day. Diagnosis: Other schizophrenia.
R47's Medication Administration History documents Aripiprazole 5mg (milligrams) ½ tablet (2.5mg) orally by mouth every day was not administered on 03/05/24.
R47's progress notes, dated 03/05/24, had no documentation of V16 notifying R47's physician of R47's missed dose of Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) orally by mouth every day on 03/05/24.
2. R1's face sheet documents R1 has diagnoses which include but are not limited to: Vitamin B 12 deficiency, Squamous cell carcinoma of skin and Bilateral primary osteoarthritis of the knee.
R1's POS, dated 02/07/24 through 03/07/24, shows R1 has an order for Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day.
R1's Brief Interview for Mental Status (BIMS), dated 02/29/24, documents R1 with a score of 15 which indicates that R1 is cognitively intact.
On 03/05/24 at 8:43 am, V16 (Licensed Practical Nurse, LPN) was observed on the second floor at the second-floor medication cart. V16 prepareed and counted 12 pills total that were administered to R1. V16 stated, I have to reorder the Vitamin B12 (cyanocobalamin). Upon surveyor reconciling R1's medication for medications that were order for administration and medications that were observed as administered and documented by V16, the following medication error was identified:
- Missed Medication: Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day.
R1's Medication Administration history documents Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day was not administered.
R1's progress notes, dated 03/05/24, had no documentation of V16 notifying R1's physician of R1's missed dose of Cyanocobalamin (vitamin B-12) tablet; 100 mcg (micrograms) 1 tablet orally every day on 03/05/24.
On 03/06/24 at 10:50 am, V2 (Director of Nursing, DON) stated the Medication Administration history shows if a medication was administered. V2 stated if a medication is not administered the Medication Administration history will have the reason the medication was not administered and the nurse on duty should notify the residents physician of the missed medication and follow through the with the physicians orders regarding the missed medication.
On 03/06/23 at 10:51 am, V2 (Director of Nursing, DON) stated medications should be given per the physicians orders. V2 also stated the importance of medication administration is to ensure the residents are receiving their medications as ordered by the physician. V2 explained the residents physician should be notified of the residents missed medication so the residents physician knows the resident missed a dose of medication and to ensure the resident is not in any harm. V2 also explained if a resident missed a dose of a psychotropic medication, the resident can have behaviors and decompensate.
The facility's document, dated July 2022, and titled Medication Administration Policy documents, Policy Specifications: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates . 19. Medications not received and /or from a pharmacy and/or administered within twenty-four (24) hours from the ordered time to be administered will be considered a medication incident. The attending physician shall be notified, and a facility designated from initiated.
The Facility's job description document titled Charge Staff Nurse documents, Position Purpose: Provide direct nursing care to the residents, and to supervise nursing activities performed by nursing assistants. Purpose of Position: . Charting and Documentation: 11. Perform routine charting duties as required and in accordance with our established Charting and Documentation Policies and Procedures . Drug Administration Functions: 1. Prepare and administer medications as ordered by the physician . 6. Ensure that an adequate supply of floor stock medications, supplies, and equipment are on hand to meet the nursing needs of the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide an environment free from hazards. This failure has the potential to affect two residents (R79 and R117) and all 45 re...
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Based on observation, interview, and record review, the facility failed to provide an environment free from hazards. This failure has the potential to affect two residents (R79 and R117) and all 45 residents on the third-floor unit at the facility.
1. On 03/04/24 at 12:45 pm, surveyor and V7 (Licensed Practical Nurse, LPN) inspected the third-floor medication cart and observed a shaving razor hanging outside of the sharps container, not properly disposed of. V7 stated, I don't know who put that there. When V7 was asked regarded the shaving razor hanging from the sharps container, V7 stated, The sharps container is not full. It (referring to the razor) should be pushed all the way inside of the sharps container. When V7 was asked regarding the importance of properly disposing shaving razors, V7 stated, I or someone can cut themselves.
On 03/6/24 at 11:03 am, V2 (Director of Nursing, DON) stated shaving razors should be properly discarded inside of the sharps containers. V2 explained shaving razors should not be visibly hanging out of the sharps containers and razors that are hanging from the sharps container and not properly disposed inside the sharps container, can fall out of the sharps container and someone can hurt themselves.
The facility's policy, dated 07/22 and titled Sharp Objects Policy, documents: Policy: To assure that sharp objects are properly container, promoting a safe environment. Policy Specifications: . 2. Place any sharp object such as needles, broken glass, etc. in a sharp container.
The facility's undated policy titled Hazardous Material and Waste Management Plan Environment of Care Management Purpose: The Hazardous Material and Waste Management Plan is designed to establish and maintain a program to safely control hazardous materials and waste . Hazardous material and infectious waste is managed and disposed of following policies and procedures. Hazardous material and waste can be, but not limited to the following: . b. Sharps, razors, lancets.
Findings include:
2. R79's Face Sheet documented R79's diagnoses include but not limited to Depression, Schizoaffective disorder, and Post-traumatic stress disorder.
R79's (01/10/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11., indicating R79's mental status as moderately impaired. Section GG. Functional Abilities and Goals. GG0130. Self-Care. I. personal hygiene: The ability to maintain personal hygiene, including shaving: 05 Set up or clean-up assistance.
R79's (10/26/2023) Preadmission Screening and Resident Review documented, Your psychiatric evaluation notes that you have a diagnoses of bipolar disorder, schizoaffective disorder, and PTSD (post traumatic stress disorder). You were easily upset, you were hard to calm down. You tried to end your life 1 year ago by cutting your writs (wrist).
R79's (10/13/2023) Care Plan documented, problem. Is limited in ability to maintain adl (Activities of daily living (personal hygiene). goal. Will be well groomed. Approach. Provide assistance for facial hair. Use (razor).
On 03/04/24 at 10:37am, there were 5 razors inside R79's water pitcher; 2 razors were covered, and the other 3 were not covered. R79 stated, The CNA (Certified Nursing Assistant) gave me the razors.
On 03/04/2024 at 10:40am, V8 (Certified Nursing Assistant) checked R79's pitcher and stated, There are 2 razors in the pitcher. I threw the other razors away. V8 then checked R79's trash can and saw 3 razors. V8 took the razors from the trash can and from R79's pitcher, and informed R79 she (V8) would keep the 2 razors with covers.
On 03/04/2024 at 10:41am, V8 stated, I gave him 2 razors this morning. He requested them (razors). I gave him shaving cream and 2 razors, and when he's done with the razor, he's supposed to give them (razors) back to me, and I am supposed to put them in the sharp container. I don't know when he got the other 3 razors. Sometimes, residents stocked the razor; but he is not supposed to do that. It is not good to keep the razors inside the resident's room because they (residents) can use it to harm themselves.
3. R117's Face Sheet documented R117's diagnoses include but not limited to schizophrenia (Primary), and Other psychoactive substance abuse with psychoactive substance-induced mood disorder.
R117's (01/16/2024) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15.,indicating R117's mental status as cognitively intact. Section GG. Functional Abilities and Goals. GG0130. Self-Care. I. personal hygiene: The ability to maintain personal hygiene, including shaving: 05 Set up or clean-up assistance.
R117's (01/23/2024) Preadmission Screening and Resident Review documented, in part What did the evaluation identify as important for a provider to know about our symptoms, diagnosis(es), behaviors or other needs and history? Your medical record notes that you have a diagnosis of schizophrenia. When mental health symptoms are present your mood can go from one extreme to anther rapidly. You have a history of hearing things that others do not hear.
R117's (07/24/2023) Care Plan documented, Problem: has a diagnosis and history of severe mental illness. Goal: use harm reduction strategies.
On 03/04/24 at 10:53am, there were 3 razors on top of R117's TV stand. V12 (Restorative Aide) stated, He (R117) has 3 razors in his room. R117 stated, I use the razor every 7days.
On 03/06/2024 at 10:50am, V1 (Administrator) stated residents who are able to use the razor should use it, and return the razor to the nurse after using it.
On 03/06/2024 at 11:00am, V2 (Director of Nursing) stated residents are not supposed to keep razors in their room. When they are finished, they should return it to the nurse for safety reason.
The (08/22) ADL Care - Shaving documented, Policy: Each resident shall receive nursing care and supervision based on individual needs. Each resident shall show evidence of good personal hygiene. ADL -care will be conducted in a private area for resident dignity. Procedure: A. To shave a resident, you will need the following: - Disposable razor; Basin of warm water; Clean wash cloth and towel; Shaving Cream; Gloves. B. 5. Change disposable razor as needed. Disposable razor must be disposed of in sharp container. 9. Dispose razor in sharp container.
The (undated) hazardous Materials and Waste Management Plan Environment of Care Management documented, Purpose: The hazardous Material and Waste management plan is designed to establish and maintain a program to safely control hazardous materials and wastes. Goals and Objectives: 2. To minimize hazards to human health and/or environment from unplanned release of hazardous materials. Hazardous material and waste can be, but not limited to the following: b. razors. Sharp containers are kept in laundry, shower rooms, med rooms, and med cart to dispose of all razors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change. These failures has the potential ...
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Based on observation, interview, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change. These failures has the potential to affect all 45 residents on the third-floor unit and all 45 residents on the fourth-floor unit at the facility.
Findings include:
On 03/04/24 at 1:10 pm, Controlled Substances Check form for the 3rd floor unit medication cart had missing signatures for the oncoming nurse on 03/02/24 11:00pm to 7:00am shift, and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift. V7, Licensed Practical Nurse/LPN stated, I don't know why it's not signed. That was not during my shift. When V7 was asked regarding the importance of the controlled substance check form, V7 stated to make sure the narcotics are all there.
The facility's document, dated March 2024 and titled Controlled Substances Check Form Station 3rd floor, shows missing signatures for 03/02/24 11:00pm to 7:00am shift and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift.
On 03/5/24 On at 11:12am, the Controlled Substances Check form for the 4th floor unit medication cart had missing signatures for 03/04/24 outgoing nurse for the 3:00pm to 11:00pm nurse. V15, LPN, stated the narcotics accountability sheet should be signed at the beginning of every shift. When V15 was asked the importance of the controlled substance check form V15 stated, To make sure the narcotics count is accurate.
The facility's document, dated March 2024 and titled Controlled Substances Check Form Station 4th floor, shows missing signatures for 03/04/24 outgoing nurse for the 3:00pm to 11:00pm nurse.
On 03/06/24 at 10:57 am, V2 (Director of Nursing, DON) stated all controlled medications should be counted by the incoming and outgoing nurses and signed after the count. V2 explained it the facility's policy for the incoming and outgoing nurses to count the medication narcotics on each medication cart to make sure the count is complete and accurate. V2 stated if the narcotics accountability count is off (not accurate), V2 should be immediately notified. V2 also stated signing the narcotics accountability sheet means the narcotics were counted and accounted for.
The facility's policy, dated 10/25/2014 and titled Controlled Substance Storage, documents,Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures: E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses or one Qualified Medication Aide (QMA) in the states who have approved such staffing positions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0914
(Tag F0914)
Could have caused harm · This affected multiple residents
On 03/04/2024 at 11:45am surveyor observed R29's and R2's room door open. R29 was observed from the open door changing her shirt and R29's upper body was naked and exposed. Surveyor observed no privac...
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On 03/04/2024 at 11:45am surveyor observed R29's and R2's room door open. R29 was observed from the open door changing her shirt and R29's upper body was naked and exposed. Surveyor observed no privacy curtains hanging from the ceiling for R29 and R2.
On 03/04/2024 at 2:30pm. V6 (CNA/Certified Nursing Assistant) stated, The privacy curtains were here on Friday (3/1/2024). I did not work the weekend. The maintenance staff took the privacy curtains down over the weekend to wash. I will call someone to see where the privacy curtains are at.
On 03/06/24 at 9:52 am, V10 (Environmental Service) stated the privacy curtains should be provided to each resident for the residents privacy. V10 stated when a residents privacy curtain is removed, the privacy curtain should be cleaned and replaced by the laundry department. V10 explained the privacy curtain should be taken down early morning and returned to the resident the same day by 1:30 pm, from the laundry department. V10 stated V10 did not know why R17, R26, and R66 did not have a privacy curtain on 03/04/24. V10 stated V10 will make sure every resident has a privacy curtain, and when a residents privacy curtain is removed, the residents privacy curtain is put back in a timely matter.
On 03/06/2024 at 3:20pm V1(Administrator) stated the Maintenance Director is responsible for maintaining and hanging the privacy curtains in the resident's rooms. V1 stated the purpose of the privacy curtain is to maintain the resident's privacy during resident care.
The facility's undated policy titled Residents Rights for People In Intermediate Care Facilities for the Developmentally Disabled document in part: Privacy: Your medical and personal care are private.
Based on observation, interview, and record review, the facility failed to provide privacy with a ceiling suspended curtain (missing privacy curtain) for five residents (R2, R17, R26, R29 and R66). This failure affected 5 out 39 residents in the total sample.
Findings include:
R17's Brief Interview for Mental Status (BIMS), dated 02/14/24, documents R17 has a BIMS score of 15, which indicates that R17 is cognitively intact.
R17's Face sheet documents R17 has diagnoses that include but not limited to: schizoaffective disorder, bipolar, hypertensive heart disease, depression, and overweight.
R26's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R26 has a BIMS score of 7 which indicates that R26 has some cognitive impairments.
R26's Face sheet documents R26 has diagnoses that include but not limited to schizophrenia, chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, depression, and peripheral vascular disease.
R66's Brief Interview for Mental Status (BIMS), dated 02/19/24, documents R66 has a BIMS score of 14, which indicates that R66 is cognitively intact.
R66's Face sheet documents R66 has a diagnosis that include but not limited to paranoid schizophrenia, anxiety disorder, depression, other insomnia, and disorder of the skin.
On 03/04/24 at 10:35 am, R17's and R26's room was observed without a privacy curtain. R17 stated R17 likes to have a privacy curtain to pull closed for R17's privacy. R17 stated, It (referring to R17's privacy curtain) has been missing for a while. I think my roommate (R26), or someone took it down. R26 stated, They (referring to staff) took it down about a month ago.
On 03/04/24 at 10:44 am, R66 was observed without a privacy curtain in R66's room. R66 stated R66 has not had a privacy curtain for a while. R66 stated R66 thinks the staff at the facility removed R66 privacy curtain from R66's room.
On 03/05/24 at 8:20 am, surveyor observed R17's and R26's and R66's room still without a privacy curtain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the handrails on the 3rd floor were firmly secured to the wall. This failure has the potential to affect all 45 reside...
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Based on observation, interview, and record review, the facility failed to ensure the handrails on the 3rd floor were firmly secured to the wall. This failure has the potential to affect all 45 residents on the third floor.
Findings include:
The (03/04/2024) facility resident's census on the 3rd floor was 45.
On 03/04/2024 at 11:48am on 3rd floor, the handrail located near the men's bathroom was not firmly secured to the wall.
On 03/04/2024 at 11:49am on 3rd floor, the handrail located near the exit was not firmly secured to the wall.
On 03/04/2024 at 11:53am, V11 (Assistant Maintenance Director) checked the handrail located near the 3rd floor's Men's bathroom and stated, It is not fixed to the wall.
On 03/04/2024 at 11:55am, V11 checked the handrail located near the 3rd floor's exit door, and stated, It is not fixed to the wall.
On 03/04/2024 at 12:11pm, V10 (Environmental Services Director) stated, The purpose of the handrail is to provide support to the residents, something for the resident to hold on to. The handrails are for residents who need support to prevent them from falling.
On 03/04/2024 at 12:12pm, V10 checked the handrail located near the 3rd floor's Men's bathroom and stated, It is loose. It is not acceptable. It is dangerous for residents who use the handrail for support. They could fall if they use this handrail.
On 03/04/2024 at 12:14pm, V10 checked the handrail located near the 3rd floor exit door and stated, The handrail is loose. It is not safe for residents to use this.
The (7/2022) Facility Policy and Procedure Equipment/Maintenance Policy and Procedures documented, All Equipment utilized in this facility shall be maintained, operated, and repaired as directed. Repair. If equipment shows sign of needing repair (e.g. handrails) staff shall immediately stop usage of the equipment and report it to maintenance.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to label and dispose of food items after the use by date. These failures have the potential to affect all 134 residents receivin...
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Based on observation, interview, and record review, the facility failed to label and dispose of food items after the use by date. These failures have the potential to affect all 134 residents receiving oral nutrition at the facility.
Findings Include:
On 3/4/24 at 9:34 am, observed in the dry storage room, a bin of rice labeled with a use by date of 3/1/24; a bin of oats labeled with a use by date of 3/1/24; and a bin of grits labeled with a use by date of 1/16/24. All labels observed for an open date was blank. V17, Dietary Manager, stated the date on the label is when the items was put into the bin. The surveyor inquired to V17, how does V17 know when the items were put into the bin when the date on the label is blank and the use by dates is 3/1/24 for the rice and oats and use by date for the grits is dated 1/16/24? V17 stated, I don't know why the staff labeled the bins like that, it's not right. Surveyor inquired how should the label be filled out. V17 stated, The entire label should be filled out.
On 3/5/24 at 2:45 pm, observed in the dry storage room, the rice bin, the oats bin, and the grits bin not labeled. V17 stated, The label was not correct with the use by dates, so we took the labels off.
On 3/6/24 at 2:00 pm, V28, Dietary Aide, stated, When putting a label on items, the whole label should be full out with the name of the item, date opened, date to use by, and your initials.
On 3/6/24 at 2:03 pm, V29, Dietary Aide, stated, Open items should be labeled with the name of the item, date when it was opened, and a use by date.
On 3/6/24 at 2:05 pm, V30, Dietary Aide, stated the entire label should be filled out. The label is important to know when the items are expired.
Facility policy (undated) and titled, Labeling and Dating Foods documents, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received the date opened and the date by which the items should be discarded. Procedure: Dry Storeroom; Package or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by.
Facility Job description titled, Food Service Supervisor, documents, Food Service Functions: 2. Procure and store food supplies. 6. Assure proper storage and handling of food and supplies.
Facility Job description titled, Dietary Aide documents, The primary purpose of the position is to provide assistance in all dietary function as directed or instructed and in accordance with established dietary policies and procedures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
3. On 3/4/24 at 12:30 pm, multiple staff on the first floor in the dining room were serving residents lunch and not performing hand hygiene in between serving trays.
On 3/4/24 at 12:45 pm, V18 (Activi...
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3. On 3/4/24 at 12:30 pm, multiple staff on the first floor in the dining room were serving residents lunch and not performing hand hygiene in between serving trays.
On 3/4/24 at 12:45 pm, V18 (Activity Aide) was touching clipboard at the desk, patting the side of V18's leg, and getting silverware. V18 did not perform any hand hygiene before going back to the serving table to get more lunch trays for the residents.
On 3/6/24 at 2:20 pm, V2, DON (Director of Nursing), stated staff should wash hands before the start of passing trays and in between passing trays. The purpose of handwashing is to prevent cross contamination with the residents.
Facility policy, reviewed 7/22, titled Hand Hygiene Policy Procedure documents, B. Indications for Hand rubbing: After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
Based on observation, interview, and record review, the facility failed to perform appropriate hand hygiene during dining, failed to appropriately sanitize dining tables between residents on the Main Dining room during dining, and failed to bag linens prior to sending the linens to the laundry area via the chute in an effort to prevent the spread of infectious microorganism. These failures have the potential to affect all the residents at the facility.
Findings include:
1. The (undated) Facility Meal times documented lunch meal times at the Main Dining room were at 12:00pm and 12:30pm.
On 03/04/2024 at 12:30pm, during the dining observation on 1st floor, some residents were leaving the dining area, and some residents were standing by waiting for available tables. V13 (Housekeeper), with gloved hands, was observed going to one of the tables, wiping the table with a green cloth with his left hand, while holding a yellow pack of disinfecting wipes with his right hand. V13 placed the used green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. A resident was observed occupying the table. V13 then proceeded to another table, wiped the table with the green cloth, while still holding the pack disinfecting wipes with his right hand. V13, again, placed the green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. This surveyor got the attention of V13, and inquired about expectation with wiping the dining tables. V13 stated, not understand English (sic). During this observation, V14 (Dietary Aide) was asking residents, who were just seated to eat, their food preference. V13 was wiping the table, again, with a green cloth with his left hand, and still holding a yellow pack of disinfecting wipes with his right hand. V13 placed the green cloth to his right hand and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. V13 proceeded to another table, wiped the table with the green cloth while still holding the disinfecting wipes with his right hand. V13 placed again the green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his left hand and wiped the table. V14 stated, (V13) did not change his gloves and he did not rinse the towel he used to clean the tables. He is not supposed to do that.
On 03/05/24 11:18 am, V2 (Director of Nursing) stated, He (V13) is supposed to remove his gloves because he already used the gloves to wipe the dirty table, and (V13) should don new gloves before going to the next table. If the staff has a sani bucket, staff is supposed to rinse the cloth towel. The purpose of changing gloves and rinsing the cloth towel is to prevent cross contamination.
On 03/05/2024 at 11:43am, V13 was at the laundry area. V10 (Environmental Services Director) translated for this surveyor and inquired about how V13 wiped the tables on the 1st floor main dining room during lunch time on 03/04/2024. V13 stated, I wiped the tables with a rag and disinfected with (disinfectant) wipes. I did not change my gloves and I did not rinse the rag in the sanitation bucket.
On 03/05/2024 at 11:45am, V10 stated, Each time he (V13) cleans a table, he is supposed to wipe the table with a rag that was in a solution of bleach and (brand name) soap, placed the dirty rag in a bucket, changed his gloves, and disinfect the table with (brand name) disinfecting wipes to prevent cross contamination.
The (07/22) Facility General Housekeeping Procedures documented, in part Purpose: To ensure a safe and clean environment. Procedure: 2. Main level dining room tables should be cleaned and sanitized before and after meals and as needed. 3. Due to the Covid-19 virus, housekeepers will wipe down items such as tables more often with proper sanitizing cleaning agent.
The (undated) Housekeeper Job Description documented, in part The primary purpose of the position is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guideline and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Housekeeping, to assure that our facility is maintained in a clean, safe and comfortable manner. Duties and Responsibilities 5. Assure that established infection control and universal precautions practices are maintained when performing housekeeping procedures.
The (undated) Hand Hygiene Policy Procedure documented, in part Purpose Effective hand hygiene reduces the incidence of healthcare-associated infections. Procedure: Indications for Handwashing: After contact with inanimate objects in the immediate vicinity of the patient. Gloves and Hand Hygiene. ear gloves when in contact with blood or other potentially infectious materials, and contaminated items will occur or could occur. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another resident.
2. On 03/05/2024 at 11:40am, V10, Environmental Services Director stated CNAs are expected to bag all linens prior to sending to the laundry area via chute to prevent cross contamination.
On 03/05/2024 at 11:41am, V10 opened the 'chute' room. There were linens in the cart under the chute opening that were not bagged. V10 stated, These linens should be bagged to prevent cross contamination.
The (03/07/2024) email correspondence with V10 documented, Subject: Residents' linens. It is expected to be bagged before going down the shoot (chute) to prevent cross contamination.
The (08/2008) Laundry and Linen documented, Purpose: the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General Guidelines. 3. Consider all soiled linen to be potentially infectious. 9. When removing soiled linen from hampers, hold plastic bags from the bottom with the opening over the washer, and empty bags directly into the washer without handling the linens.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services, thus resulting in a male resident...
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Based on interview and record review, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services, thus resulting in a male resident (R1) physically assaulting another male resident (R2) for two out of 24 residents reviewed for physical abuse.
Findings include:
R1's care plan documents in part: Problem: BEHVAIORAL SYMPTOMS: The resident displays behavioral symptoms related to: (X)Severe mental illness. These behavioral symptoms are manifested by: Verbally inappropriate behavior, Comments, details and frequency: Resident has a history of displaying aggressive behaviors.
R1's Psychosocial Assessment (11/21/2023) documents in part: Barriers to learning, psychosis.
On 12/19/2023 at 10:15 AM, R1 was interviewed in the conference room. R1 was observed being seated in his wheelchair. R1 stated he has gotten into fights in the past. He said his last fight was on the patio where someone said something to him, and he punched him in the face.
On 12/19/2023 at 11:00 AM, V3 (Licensed Practical Nurse) stated he heard there was a fight that happened last week, but didn't know what happened. When asked how he heard, V3 stated he overheard a resident swearing at another resident saying, I'm going to beat his ass. V3 stated he didn't know who that resident was. V3 stated he didn't tell anyone.
On 12/19/2023 at 11:45 AM, R3 was seen eating lunch in his room. R3 stated sometime last week, he was on the elevator with R1 and R2. Once the elevator stopped on the 3rd floor, R3 stated he got out. R3 stated he saw R2 also get out by mistake, but then wanted to get back into the elevator. R3 stated R1 refused R2 to enter back into the elevator, and then he heard yelling and the elevator shaking. R3 then stated he saw R2 coming out of the elevator stating R1 hit him in the face. R3 stated he has seen R1 get into fights and verbal aggression with others.
On 12/19/2023 at 12:05 PM, R2 was seen laying in his bed. R2 was calm. R2 stated that last week on Wednesday, R1 punched him in the face. R2 stated he was on the elevator and got off on the 3rd floor accidentally; when we tried to get back on, R1 swore at him to stay off the elevator, and then punched him in the face. This incident frightened me because growing up I had an abusive mother and father. R2 stated he has Aspergers and this incident triggers memories from the past.
Facility's Abuse Policy documents in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical, mental or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting by physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury upon a resident that occurs by hitting slapping, pinching, kicking, and controlling behavior through corporal punishment, which requires medical attention.
May 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to label and date oxygen equipment (oxygen tubing and humidifier bottle). This failure affected one resident (R332) reviewed for...
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Based on observation, interview, and record review, the facility failed to label and date oxygen equipment (oxygen tubing and humidifier bottle). This failure affected one resident (R332) reviewed for oxygen equipment in a total sample of 37 residents.
Findings include:
R332 has an admission diagnoses of, but not limited to: schizoaffective disorder, chronic systolic heart failure, Atherosclerotic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, and obstructive sleep apnea.
R332's BIMS ( Brief Interview for Mental Status), dated 4/10/23, score is 15. R332 is cognitively intact.
On 5/1/23 at 10:45 am, observed R332's lying in bed receiving oxygen through an oxygen nasal tube at 2 liters/minute. R332's oxygen tubing and humidifier bottle were undated.
On 5/2/23 at 9:30 am, observed R332's oxygen tubing and humidifier bottle undated.
R332's Physician Order Sheet (POS), dated 4/6/23, documents, in part, change tubing and mask weekly and PRN (as needed) label once a day on Sundays.
R332's care plan, dated 4/13/23, documents in part, Problem: R332 has COPD (Chronic Obstructive Pulmonary Disease), Approach; on Oxygen PRN, apply as ordered by MD (Medical Doctor).
On 5/2/23 at 10:00 am, V17 ,LPN (License Practical Nurse), stated the oxygen tubing and humidifier should be changed weekly on Sundays. Surveyor inquired to V17 if a date is on R332's oxygen tubing and humidifier bottle. V17 stated, I do not see a date. A date should be on the tubing and bottle at time of change.
On 5/2/23 at 10:15 am, V21, ADON (Assistant Director of Nursing), stated, Oxygen tubing is changed weekly. The oxygen tubing and humidifier bottle should have a date to indicate the last time it was changed. The surveyor inquired if V21 could see a date on R332's oxygen and humidifier bottle, and V21 stated, I do not see a date on the tubing or humidifier bottle. V21 stated R332 just came back from the hospital recently. Surveyor inquired to R21 should there still be a date on the oxygen tubing and bottle. V21 stated, Yes, there still should be a date.
On 5/3/23 at 2:40 pm V2, DON (Director of Nursing), stated, Oxygen tubing and humidifier bottles are changed weekly on the weekends. There should be a date on the oxygen tubing and humidifier bottle when it is changed.
Facility policy titled Oxygen Administration, undated, documents in part, Steps in the Procedure: 18. Make sure the oxygen humidifier jar is labeled properly.
Facility Job description titled Nurse, documents in part, Administrative Functions. (2) Ensure that all written policies and procedures that govern the day-to-day functions of the nursing department are followed. (3) Ensure that the Nursing Services Procedure Manual is followed in rendering nursing care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to properly log refrigerator temperatures for one resident's (R122) personal refrigerator.
Findings include:
On 5/1/2023 at 2:0...
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Based on observation, interview, and record review, the facility failed to properly log refrigerator temperatures for one resident's (R122) personal refrigerator.
Findings include:
On 5/1/2023 at 2:03 pm, R122 had a black colored refrigerator with a freezer at the top and refrigerator on the lower portion in his room. Surveyor observed no temperature log affixed in or near the refrigerator, and no thermometer in the freezer portion or the refrigerator portion of the refrigerator. R122 stated the facility staff have not been checking the temperature in the refrigerator daily,
On 5/2/23 at 1:55 pm, R122's refrigerator had no thermometer in the inside of the freezer portion or refrigerator portion and no refrigerator temperature log affixed to the personal refrigerator. The following foods were located inside the refrigerator at the time of observation: 1 orange, 1 can of fruit cocktail, and 1 banana. The freezer portion of the refrigerator contained 1 package of frozen beef stew and 1 package of frozen vegetables.
On 5/3/2023 at 10:02 am, V26(Environmental Services) stated, I don't know who is checking the temperature in (R122's) refrigerator. I only check the top of the nightstand for trash and clean the room. I don't check the refrigerator's temperature.
On 5/3/2023 at 10:40 am, V13(Environmental Services Director) stated, (R122) got the refrigerator in February 2023. The environmental services staff has not checked the temperature in (R122's) refrigerator since (R122) got the refrigerator in February 2023. V13 stated there is no refrigerator temperature log for R122's refrigerator. V13 stated food items can spoil if the refrigerator is not working properly and the temperature is not with an acceptable range. V13 stated if R122 eats spoiled foods, R122 can get sick.
On 5/3/2023 at 10:48 am, V27(CNA/Certified Nursing Assistant) stated, I don't check the temperatures for (R122's) personal refrigerator.: V27 stated if the temperature in the refrigerator is not within an acceptable range, then the foods in the refrigerator will spoil. V27 stated if the resident eats spoiled food, the resident may get sick.
R122's Brief Interview for Mental Status (BIMS), dated 2/7/2023 Section C C0500, documents R122 has a BIMS score of 15, which indicates that R122 is cognitively intact.
Facility's undated policy titled Food Brought in By Family or Visitors/ Personal Refrigerators underneath Procedure documents, in part, Personal refrigerator temperatures are maintained at 41 degrees F(Fahrenheit) or below.
Director of Environmental Services job description documents, in part, The primary purpose of the position is to plan, organize, develop, and direct the overall operation of the Housekeeping, Laundry and Maintenance Departments in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe and comfortable manner.
The facility did not present refrigerator temperature logs from February 2023(when R122 obtained the refrigerator in his room) until May 4, 2023, to the surveyor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility staff failed to complete the controlled substances check form, which is utilized to complete a shift-to-shift count for controlled subs...
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Based on observation, interview, and record review, the facility staff failed to complete the controlled substances check form, which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 47 residents on the second floor.
Findings include:
On 05/02/2023 at 10:55 am with V3(LPN/Licensed Practical Nurse), surveyor reviewed the second-floor medication cart Controlled Substance Check Form for April 2023. This form is used by the facility for shift change accountability for controlled substances. The Nurse On and/or Nurse Off initial boxes were left blank/missing initials for:
April 27, 2023, 11pm-7am shift-on nurse
April 28, 2023, 7am-3pm shift-off nurse
April 28, 2023, 11pm-7am shift-on nurse
April 29, 2023, 7am-3pm shift-off nurse
April 29, 2023, 11pm-7am shift-on nurse
April 30, 2023, 7am-3pm shift-on nurse and off nurse
April 30,2023 3pm-11pm shift-off nurse
April 30, 2023, 11pm-7am shift-on nurse, indicating controlled substance reconciliation at the end and beginning of shifts was not completed.
On 05/02/2023 at 11:32 am, V3(LPN/Licensed Practical Nurse) stated, Two nurses are to sign on and sign off on the controlled substances check form, when the nurses are changing shifts. The purpose of the controlled substances check form is the make sure two nurses have counted the controlled substances in the medication cart, and the count for the controlled substances is correct. The nurses are to notify the Director of Nursing if the controlled substances check form is not completed by both nurses, and/or the count for the controlled substances is not correct.
On 05/03/2023 at 10:29 am, V2(Director of Nursing) stated the nurses are responsible for completing the controlled substances check form. V2 stated the incoming nurse is to count the controlled substances with the outgoing nurse. V2 stated this is done to ensure that the count of the controlled substances is correct. V2 stated the form should be initialed by the incoming and outgoing nurses, this is verifying that both nurses have counted the controlled substances and agree that the count for the controlled substances is correct. V2 stated the DON (Director of Nursing) should be notified if the controlled substances check form is not initialed and completed for each shift.
Facility's policy (dated 10/25/2014) titled Receiving Controlled Substances, which documents, in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements by the facility in accordance with federal and state laws and regulations.
Facility's undated job description for RN (Registered Nurse) and LPN (Licensed Practical Nurse) which documents, in part, underneath charting and documentation 11. Perform routine charting duties as required and in accordance with our established charting and documentation policies and procedures.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include:
2. On 05/01/2023 at 11:25am, there were residents going in and out of the 2nd floor dining; some were watchin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include:
2. On 05/01/2023 at 11:25am, there were residents going in and out of the 2nd floor dining; some were watching television. Observed one of the wall electrical plugs was not fully covered and there was exposed wiring. V15 (Certified Nursing Assistant) stated, This is an old building but you can still use the plug.
On 05/01/2023 at 11:32am, this surveyor pointed out to V13 (Environmental Services Director/Maintenance Director) the condition of the electrical wall plug, and he (V13) stated, It should not be like that, it is a safety issue. It is a hazard to the residents.
The (Revised 01/05) Director of Environmental Services documented, in part Purpose of the Position. The primary purpose of the position is to plan, organize, develop, and direct the overall operation of the Housekeeping, laundry and Maintenance Departments in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe and comfortable manner. Environmental Service functions. 1. Assure the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform necessary duties and services. 9. Other(s) that may become necessary/appropriate to assure that our facility in maintained in a clean, safe and comfortable manner.
The (undated) Residents' Rights for People in the Long-Term Care Facilities documented, in part Your rights to safety. Your facility must be safe.
Based on observation, interview, and record review, the facility failed to maintain the walls and base boards of the second floor dayroom, bathroom, and hallway in good repair, and failed to repair one electrical outlet in the dayroom. This failure has the potential to affect all 47 residents on the second floor.
Findings include:
1. On 5/1/23 at 10am during the entrance conference, V1(Administrator) presented the facility's census that shows 47 residents live on the second floor.
On 05/1/23 between 11:15am and 11:50am during observation of residents on the second floor, the following was observed:
Broken and chipped wall, and chipped and missing base-board at the entrance of the women's bathroom across from the day-room; Door side of the day-room has peeling paints; Chipped tiles by the door of room [ROOM NUMBER] and by the janitor's closet; Peeling paints on the double doors in the hallway; Tub and Shower room has rusted and broken base boards, peeling wall covers by room the door of room [ROOM NUMBER], 202, 206, 208, and 203(across from the stairway); Peeling paint in room [ROOM NUMBER] by the bathroom.
On 5/2/23 at 10:30am, the second floor dayroom and hallway were still in the same condition. At this time, two residents R57 and R71 were asked if the peeling paints and walls and base boards disrepair are recent. All 3 residents stated they've been there for as long as they remember.
On 5/2/23 at 11:01am, V13(Environmental Services Director) was interviewed regarding all areas of the second floor in disrepair. V13 stated he(V13) would walk through the second floor and do the repairs.
Facility's policy titled Equipment Maintenance Policy and Procedures, revised July 2022, states in part, under Maintenance: Any holes, baseboards, or broken wall structures must be repaired to ensure no safety or pest control issues arise.
Facility's Job Description for Director of Environmental Services states in #7: Make weekly inspections of all environmental services functions to assure that quality control measures are continually maintained. #16 states: Maintain and repair if needed the proper function of all facility equipment. #17 states: Maintain a preventative maintenance program.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the handrail on the 2nd floor is firmly secure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the handrail on the 2nd floor is firmly secured to the wall. This failure has the potential to affect all 47 residents on the second floor.
Findings include:
The (05/01/2023) facility resident's census in 2nd floor was 47.
On 05/01/2023 at 11:19am on second floor, the handrail on the hallway, adjacent to room [ROOM NUMBER], was loose. V14 (Restorative Aide) stated, The handrail is broken. During this time, V13 (Maintenance Director) came. This surveyor pointed out to V13 the condition of the handrail. V13 checked the handrail, and stated the handrail is loose. V13 stated, the purpose of the handrail is for residents to support themselves when they are walking. It is a hazard if the handrail is loose. The residents could fall when they used it because it loose.
The (undated) Facility Policy and Procedure Equipment/Maintenance Policy and Procedures documented, in part All Equipment utilized in this facility shall be maintained, operated, and repaired as directed. Repair. If equipment shows sign of needing repair (e.g. handrails) staff shall immediately stop usage of the equipment and report it to maintenance.
The (undated) Residents' Rights for People in the Long-Term Care Facilities documented, in part Your rights to safety. Your facility must be safe, clean, comfortable and homelike.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to follow their policy of labeling and dating of food items, and failed to dispose of food items that passed the 'use-by-date' t...
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Based on observation, interview, and record review, the facility failed to follow their policy of labeling and dating of food items, and failed to dispose of food items that passed the 'use-by-date' to ensure the effectiveness of the food item and in an effort to prevent food-borne illnesses. These failures have the potential to affect all 136 residents in the facility.
Findings include:
The (05/01/2023) residents census was 136.
The (05/03/2023) email correspondence with V1 (Administrator) documented there were no NPO (nothing by mouth) residents in the facility.
On 05/01/2023 at 9:54 am inside the dry storage room, there were containers of Ready Care Orange Juice, Pomegranate and Water that have 'use-by-date' of 05 April 2023, 15 April 2023, and 16 April 2023. These food items were stocked behind the containers of Ready Care that were dated July 2023. V8, Dietary Services Director, stated, The staff did not do the First In First Out when they stocked the Ready Care. The new delivery should be stocked at the back. We (Facility) cannot give these to the residents, it's been almost a month since the use by date. The older it gets, the more it is not good for the residents. We don't know if there something in there that is harmful for the resident.
On 05/01/2023 at 10:04 am, still in the Dry Storage Room, the [NAME] bin and Oatmeal bin were dated 2022 and 2023 respectively, with no 'month' or 'day'. V8 stated, I (V8) don't know when these came in the facility. I (V8) will inform my staff to make sure the bins are completely dated so we know if these are old or not, we don't want to serve old food to the residents.
On 05/04/2023 at 12:38 pm, surveyor inquired about staff expectation with the Ready Care thickened liquid once these passed the 'use-by-date'. V28 (Registered Dietician Consultant) stated, Staff are expected to toss them away. These are no longer good. The consistency may already change. The product may have expired already and it may not be as effective.
The (undated) Food Service Supervisor Job Description documented, in part Purpose of the Position. The Primary purpose of the position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with current federal, state and local standards, guideline and regulation governing our facility, and as ma be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department in maintained in a clean, safe, and sanitary manner. Food Service Functions. Assure proper storage and handling of food and supplies.
The (undated) Facility Policy and Procedure Storage of Dry Goods/Foods documented, in part Policy: Non-refrigerated foods, disposable dishware and other goods are stored in a clean, dry area, which is free from contaminants. Procedure: Foods stored in bins is removed from original packaging. Bins are labeled and dated.
The (undated) Facility Policy and Procedure Labeling and Dating Foods documented, in part Policy: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, date opened and the date by which the item should be discarded. Procedure: Packaged or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by.
The (undated) Facility Policy and Procedure Use By Date Recommendations documented the recommended maximum storage period if opened and expiration date not exceeded for Cereals is 12 months on shelf and for [NAME] 1 year on shelf.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Illinois facilities.
- • 25% annual turnover. Excellent stability, 23 points below Illinois's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
- • 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is All American Vlge Nrsg & Rhb's CMS Rating?
CMS assigns ALL AMERICAN VLGE NRSG & RHB an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is All American Vlge Nrsg & Rhb Staffed?
CMS rates ALL AMERICAN VLGE NRSG & RHB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 25%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at All American Vlge Nrsg & Rhb?
State health inspectors documented 32 deficiencies at ALL AMERICAN VLGE NRSG & RHB during 2023 to 2025. These included: 32 with potential for harm.
Who Owns and Operates All American Vlge Nrsg & Rhb?
ALL AMERICAN VLGE NRSG & RHB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 144 certified beds and approximately 137 residents (about 95% occupancy), it is a mid-sized facility located in CHICAGO, Illinois.
How Does All American Vlge Nrsg & Rhb Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, ALL AMERICAN VLGE NRSG & RHB's overall rating (2 stars) is below the state average of 2.5, staff turnover (25%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting All American Vlge Nrsg & Rhb?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.
Is All American Vlge Nrsg & Rhb Safe?
Based on CMS inspection data, ALL AMERICAN VLGE NRSG & RHB has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at All American Vlge Nrsg & Rhb Stick Around?
Staff at ALL AMERICAN VLGE NRSG & RHB tend to stick around. With a turnover rate of 25%, the facility is 20 percentage points below the Illinois average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was All American Vlge Nrsg & Rhb Ever Fined?
ALL AMERICAN VLGE NRSG & RHB has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is All American Vlge Nrsg & Rhb on Any Federal Watch List?
ALL AMERICAN VLGE NRSG & RHB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.