Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at All American Vlge Nrsg & Rhb during CMS and state inspections, most recent first.
Two cognitively intact residents with psychiatric diagnoses engaged in repeated verbal aggression, including mutual name-calling, cursing, threats, and allegations of spitting, which staff identified as verbal abuse. Despite this history and ongoing provocation between them in shared areas such as the lobby and elevator, they continued to encounter each other, and no effective measures are described to prevent further escalation. During a later encounter near the elevator, one resident approached the other and struck first, leading to a physical fight in which both exchanged blows before staff intervened. One resident sustained a bleeding laceration above the eye and the other had forehead redness and bruising, and the injured resident later reported feeling unsafe and fearful for his life, ultimately leaving AMA. The surveyors determined the facility failed to protect residents from verbal and physical abuse, resulting in actual harm.
Three residents were not protected from abuse, resulting in one losing a dental implant and tooth after being punched, and two others sustaining injuries during a physical altercation over a TV remote. Staff and medical records confirmed the incidents, which occurred despite facility policies prohibiting abuse and requiring resident safety.
The facility managed the personal trust funds of two residents without obtaining the required written authorization, as mandated by facility policy. One cognitively intact resident refused to sign the authorization and later exhibited aggressive behavior and was hospitalized after discovering the facility had assumed control of her funds without consent. The Business Office Manager confirmed that written authorization was not obtained for these residents.
A resident with moderate cognitive impairment and a history of mental illness was placed in a room with another resident known for severe cognitive impairment and repeated aggressive behaviors, including physical aggression toward others. Despite documented behavioral issues and a care plan indicating the need for separation, no specific interventions or monitoring were implemented after the room transfer. This resulted in a physical assault, with staff unaware of the rationale for the room assignment and the room not being located near the nurse station as believed.
The facility failed to properly label, date, and discard food items, and did not monitor refrigerator and freezer temperatures as required, potentially affecting 138 residents. Several food items lacked proper labeling, and temperature logs showed missing entries, indicating non-compliance with the facility's policies.
The facility failed to implement a plan to prevent Legionella growth in its water system, potentially affecting all 137 residents. The Maintenance Director admitted there is no plan or documentation for Legionella testing, despite having implemented such measures at previous employment. The facility's policy requires reducing Legionella risk, aligning with CMS directives for Medicare-certified facilities to maintain water management policies.
The facility failed to manage medications properly, including not documenting administration, not following inhaler instructions, administering late medications without notifying a doctor, and keeping a medication without an expiration date. These actions could lead to medication errors and affect therapeutic levels for residents.
The facility's call light system was found to be non-functional for eleven residents, as observed during a survey. When activated, the call lights did not illuminate or emit sound, preventing residents from requesting assistance. Staff, including CNAs and the DON, were unaware of the issue until the survey, despite recent maintenance attempts. The facility's policy mandates a functioning call light system, which was not met.
A facility failed to respect a resident's right to privacy and dignity when a CNA was found searching a resident's room and personal belongings without consent. The resident, who was cognitively impaired and had multiple health issues, was not present during the incident. The CNA admitted to being in the room during a lunch break, despite not being assigned to the resident, and acknowledged the violation of the resident's rights. The facility's policy mandates respect and dignity for residents, which was not upheld in this case.
A resident was found wearing a hospital wristband displaying personal health information, which was not removed upon readmission to the facility. This oversight was acknowledged by the DON and violated HIPAA regulations, as it exposed the resident's private information to unauthorized individuals.
A facility failed to update the PASARR screening for a resident, resulting in an expired assessment. The resident's SLP setting was deemed appropriate, but the initial screen and comprehensive assessment were not renewed within the 90-day validity period. Staff interviews revealed a lack of awareness and communication regarding the expiration, with the Business Office Manager and Social Services Director both unaware of the need for an update.
A facility failed to conduct a required Level I PASRR screening for a resident with mental illness, relying on an outdated OBRA-I Initial Screen. The resident was admitted before PASRR requirements, and the oversight was acknowledged by the Administrator and Business Office Manager, who was auditing charts to ensure compliance.
A facility failed to monitor a resident's ileostomy site every shift as ordered by the physician. The resident, with an intact cognition and diagnosed with an ileostomy, expressed concerns about the lack of care. The Treatment Administration Record showed multiple missed monitoring instances, and a nurse consultant confirmed these omissions. The facility's policy requires documentation of care, which was not consistently followed.
A resident with intact cognition received expired milk for breakfast, which was confirmed by a surveyor. The facility's policy requires checking expiration dates before serving, but this was not followed, leading to the incident. The Dietary Manager explained the procedure for handling milk, but the expired milk was still served, indicating a lapse in protocol.
The facility failed to monitor antibiotic use for three residents, as the IP, new to the role, discovered there was no system in place to track antibiotic prescriptions. Some residents were prescribed antibiotics without end dates, contrary to the facility's policy on antibiotic stewardship, leading to a deficiency in monitoring and reviewing antibiotic use.
The facility's heating system failed due to water leakage from a rusted water heater tank, affecting all residents during cold temperatures. The Maintenance Director reported that the boiler control system was damaged, preventing the facility from maintaining the required temperature. Residents experienced discomfort, needing extra blankets and moving away from windows. The facility lacked a regular maintenance schedule for the heating system, and temperature logs were incomplete, contributing to the problem.
The facility failed to conduct comprehensive pre-employment background checks on new hires, including a supervisor and CNAs, before they began working. Required checks on offender registries were not completed, and documentation lacked initiation dates, potentially affecting resident safety.
A resident reported her designer eyeglasses were stolen, but the LTC facility failed to investigate or report the incident to the State Agency. Despite the resident's cognitive intactness and detailed account, staff did not take appropriate action. The LPN informed the DON, but no investigation followed. The Administrator later acknowledged the oversight, and a report was only made after surveyor involvement.
A resident with multiple health issues was transferred to a hospital due to lethargy and abnormal vital signs. However, the documentation of this event was improperly recorded under another LPN's credentials, who did not assess the resident. The LPN who documented the event used a colleague's access due to computer access issues, violating facility policies on secure and accurate record-keeping.
The facility failed to maintain an effective pest control program, resulting in mice and roaches in resident rooms and common areas. Residents reported seeing pests, and housekeeping confirmed the presence of droppings and live roaches. The pest control company only treated common areas unless directed to specific rooms, leading to ongoing pest issues and resident complaints.
Failure to Prevent Escalating Resident-to-Resident Abuse Resulting in Eye Injury
Penalty
Summary
The deficiency involves the facility’s failure to affirm residents’ right to be free from verbal and physical abuse, specifically in relation to repeated conflicts between two cognitively intact residents, R2 and R4. Both residents had psychiatric diagnoses, including bipolar disorder and other mood/psychotic disorders, and required setup help to supervision with ADLs. On a date in early March, R2 and R4 engaged in a verbal altercation near the first-floor elevator and patio area. Security staff (V19) reported that both residents were calling each other derogatory names, cursing, making threats, and provoking one another to fight. R4 alleged that R2 spat on him during this encounter, but security did not witness any spitting, and witnesses did not observe the alleged incident. The facility’s first incident report to the state documented that R4 reported being spat on by R2, which R2 denied, and that witnesses did not corroborate the spitting. Following this initial verbal abuse incident, both residents were reportedly sent to the hospital for evaluation and later returned to the facility. After their return, R2 stated that R4 continued to provoke him on multiple occasions, including coming to R2’s floor and attempting to initiate fights when they passed each other, with staff intervening and separating them. R4 reported that he had been reassured the situation had been resolved but continued to feel fearful of R2 and unsafe in the facility. Despite the known history of verbal aggression and mutual provocation, both residents continued to encounter each other in common areas such as the lobby and elevator area, and the record does not describe any effective measures taken to prevent further contact or escalation between them prior to the subsequent physical altercation. On a later date in March, a physical altercation occurred between R2 and R4 near the first-floor elevator. Multiple staff witnesses (V6, V7, V18) consistently reported that R4 approached R2 as R2 was near or at the elevator, and that R4 swung first, striking R2 in the face. R2 then struck back, with witnesses describing both residents swinging at each other until staff intervened. R4 sustained a small open area or cut above the left eyebrow with bleeding, and R2 had redness and a bruise to the forehead. Nursing staff documented that both residents were separated and placed on one-to-one monitoring, and that R4 had a superficial open area above the left eyebrow that required first aid and steri-strips. R4 later stated that he felt fearful for his life due to R2’s presence in the facility and that he chose to leave against medical advice because he no longer felt safe. The surveyors concluded that the facility failed to protect R4 and R2 from verbal and physical abuse by not effectively preventing or managing the escalating pattern of resident-to-resident aggression, resulting in actual harm to R4 when he sustained a left eye injury.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect three residents from abuse, resulting in significant physical harm. One resident with a history of schizoaffective and bipolar disorder, who was experiencing delusions and agitated behavior, entered another resident's room and punched them in the mouth. This incident caused the victim to lose a dental implant and a natural tooth, resulting in bleeding and distress. Multiple staff interviews and medical records confirmed the physical altercation and the extent of the dental injuries, which required further dental evaluation and treatment. In a separate incident, two roommates were involved in a physical altercation over a television remote. One resident attempted to retrieve the remote from the other, leading to a physical struggle in which one was kicked in the face and responded by punching the other in the head multiple times. Both residents sustained injuries: one had a laceration to the upper lip, and the other complained of a headache after being kicked in the head. Staff interviews and hospital records corroborated the sequence of events and the resulting injuries. The facility's own policies affirm the right of residents to be free from abuse, including physical harm inflicted by others. Despite these policies, the incidents described involved residents inflicting physical harm on each other, with staff only becoming aware after the events had occurred. The facility's monitoring and supervision were insufficient to prevent these abusive incidents, as evidenced by the residents' ability to engage in physical altercations resulting in injury.
Failure to Obtain Written Authorization for Management of Resident Trust Funds
Penalty
Summary
The facility failed to obtain proper written authorization to manage the personal trust funds of two residents. One resident, who was cognitively intact and able to express her wishes, refused to sign the authorization paperwork, stating she could manage her own finances. Despite this, the facility proceeded to manage her funds, including becoming the representative payee for her Social Security benefits without her consent. The resident became aware of this change after contacting Social Security and observing facility staff handling documents related to her finances. This led to significant agitation, aggressive behavior, and ultimately, the resident being hospitalized. Additionally, the facility managed another resident's funds without obtaining written authorization, as confirmed by the Business Office Manager, who stated that the majority of residents did not have such authorization on file. The facility's own policy required residents or their representatives to sign an authorization form before the facility could manage personal funds, but this procedure was not followed for these two residents.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Care Planning and Monitoring
Penalty
Summary
The facility failed to establish an environment that promotes resident sensitivity, safety, and prevention of mistreatment, resulting in an incident of abuse between two residents. One resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment was placed in a room with another resident who had a history of severe cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and repeated aggressive behaviors toward staff and other residents. Despite multiple documented incidents of aggression and behavioral concerns for the second resident, including physical aggression, verbal outbursts, and the need for antipsychotic medication, there was no documented care plan or intervention specifically addressing abuse prevention for the first resident after the room transfer. The care plan for the aggressive resident indicated a need for separation from others as needed due to behavioral symptoms, but this intervention was not implemented when the two residents were placed together. Staff interviews revealed a lack of awareness regarding the rationale for the room assignment and an absence of specific interventions to prevent abuse following the transfer. The aggressive resident's care plan also called for ongoing assessment for aggression, but there was a gap in aggression assessments between the date of the care plan intervention and the actual abuse incident. On the day of the incident, the resident with moderate cognitive impairment was physically assaulted by the aggressive resident, resulting in injuries to his ribs and head. Staff responded after hearing commotion, but the incident occurred quickly and without prior intervention. The room where the incident occurred was not located near the nurse station, contrary to staff belief that it was, and there was no evidence that enhanced monitoring or other preventive measures were in place at the time of the incident.
Failure to Properly Label and Monitor Food Storage
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items, as well as monitoring of refrigerator and freezer temperatures, which could potentially affect 138 residents. During an inspection, several food items in the reach-in refrigerator and dry foods/spice pantry were found without open dates, use by dates, or with unreadable labels. For instance, a container of nacho jalapeno peppers had an open date of 02/08/25 and an expiration date of 03/20/2025, but was not discarded as required. Other items, such as giardiniera mild pepper mix and sweet relish, lacked proper labeling, making it difficult to determine their freshness and safety for consumption. Additionally, the facility did not adhere to its policy of monitoring refrigerator and freezer temperatures twice daily. Temperature logs for the reach-in refrigerator, walk-in refrigerator, and walk-in freezer showed no entries for evening temperatures from 04/01/2025 to 04/08/2025, and no morning temperature entries for 04/09/2025. The Dietary Service Director acknowledged that the cooks were only checking temperatures once per day, contrary to the policy that requires three checks per day. This lack of monitoring could compromise the safety and quality of stored food items.
Failure to Implement Legionella Prevention Plan
Penalty
Summary
The facility failed to implement a plan to prevent the growth of Legionella bacteria in its water system, which has the potential to affect all 137 residents residing in the facility. During an interview, the Maintenance Director/Housekeeping Director, who has been working at the facility for approximately five months, admitted that there is no plan in place to check the facility's water system for Legionella. He also stated that he could not find any previous documentation indicating that the facility's water system had been tested for Legionella. Despite having implemented Legionella water testing at his previous employment, he has not done so at this facility. The facility's policy, dated 2023, outlines the need to reduce Legionella risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease and other waterborne pathogens. The Centers for Medicare & Medicaid Services (CMS) requires Medicare-certified healthcare facilities to develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella. The facility's failure to have a documented water management program in place is a direct violation of this directive, as it lacks measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage pharmaceutical services, resulting in several deficiencies. A Licensed Practical Nurse (LPN) did not document the administration of medications for a resident, which could lead to medication errors such as double dosing. Another LPN administered an inhaler to a resident without following the pharmacy's instructions to wait between puffs, potentially affecting the medication's absorption and effectiveness. Additionally, a resident's medications were administered late without notifying the doctor, which could disrupt therapeutic levels necessary for managing the resident's illnesses. Furthermore, during a review of the medication cart and room, a bottle of Ferrous Sulfate was found without an expiration date, raising concerns about its efficacy and safety. The Director of Nursing acknowledged that medications without expiration dates should be removed to prevent potential adverse effects. The facility's Medication Administration Policy emphasizes timely administration and proper documentation, which were not adhered to in these instances, leading to the identified deficiencies.
Non-Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system for eleven residents, as observed during a survey. On multiple occasions, when the call light was activated in various resident rooms, the light above the door did not illuminate, and no audible sound was heard. This issue was confirmed by both the Certified Nursing Assistants and the Director of Nursing, who acknowledged that the call light system is essential for residents to request assistance, especially in emergencies. Despite the presence of a call light in each room, the system was not operational, preventing residents from effectively communicating their needs to the staff. The Director of Nursing and other staff members were unaware of the malfunctioning system until it was pointed out during the survey. It was noted that someone had been working on the system the previous week, but the issues persisted, with no sound being emitted from the system. The facility's policy requires a functioning call light system, yet the survey revealed that the system was not meeting this requirement, as evidenced by the lack of response when the call lights were activated.
Violation of Resident's Right to Privacy and Dignity
Penalty
Summary
The facility failed to honor a resident's right to be treated with respect and dignity by searching a resident's room and personal property without the resident's knowledge and consent. This incident involved a male resident with multiple diagnoses, including hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of the prostate. The resident was cognitively impaired, as indicated by a BIMS score of 11/15. On the specified date, a Certified Nursing Assistant (CNA) was observed sitting on the resident's bed with his hand inside the resident's nightstand, while another CNA was sitting at the foot of the bed. The resident was not present in the room at the time. The CNA admitted to being in the room during his lunch break and acknowledged that he should not have been inside the resident's room without the resident's knowledge, especially since he was not assigned to care for the resident that day. The Director of Nursing confirmed that staff members should not be in residents' rooms during their breaks and should not search through residents' personal belongings without permission. The facility's policy emphasizes treating residents with respect and dignity, which was violated in this instance.
Resident Privacy Violation Due to Hospital Wristband
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information. A resident, identified as R33, was observed sitting in the dining room wearing a white hospital wristband that displayed his full name, date of birth, age, and medical record number. This wristband was placed on him during a hospital stay and was not removed upon his return to the facility, thereby exposing his private health information to anyone who could see it. The Director of Nursing (DON) acknowledged the oversight when it was brought to their attention and confirmed that the wristband should have been removed upon the resident's readmission to the facility. The facility's policy on Health Information Management mandates that all resident-identifiable information be kept confidential and only disclosed to authorized individuals. The failure to remove the wristband resulted in a violation of the Health Insurance Portability and Accountability Act (HIPAA), as it allowed unauthorized access to the resident's personal health information.
Failure to Update PASARR Screening for Resident
Penalty
Summary
The facility failed to initiate a new Pre-Admission Screening and Resident Review (PASARR) for a resident, referred to as R79, who was reviewed for PASARR in a sample of 27 residents. R79's documentation indicated that an SLP (Supportive Living Program) setting was deemed appropriate, and the initial screen and comprehensive assessment were valid for up to 90 days. However, the facility did not update the PASARR screening within this timeframe, resulting in an expired assessment. Interviews with facility staff revealed a lack of awareness and communication regarding the expiration of R79's PASARR screening. The Business Office Manager, who had been in the role for only 11 days, was responsible for inputting resident information into the PASARR system but was unsure of R79's screening results. The Social Services Director, responsible for updating PASARR screenings, was not aware of the expiration and had not received any notification about it. The facility's policy mandates that the transferring facility is responsible for ensuring the correct PASARR paperwork is in place, but this was not adhered to in R79's case.
Failure to Conduct PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to initiate a new Level I Pre-Admission Screening and Resident Review (PASRR) for a resident with a known mental illness, identified as R40. R40 was admitted to the facility with diagnoses including schizoaffective disorders, bipolar disorder, and major depressive disorder. Despite these diagnoses, the facility did not have a current PASRR screening for R40, as the resident was admitted before PASRR screenings were required. The facility relied on an outdated OBRA-I Initial Screen from 2004, which indicated a reasonable basis for suspecting mental illness. During the survey, the Administrator (V1) acknowledged the absence of a PASRR screening for R40 and mentioned that a request for the screening was made only recently. The Business Office Manager (V20), who had been in the position for just 13 days, confirmed that the facility had not conducted a PASRR screening for R40, as it was overlooked during the transition to the current requirements. V20 was in the process of auditing resident charts to ensure compliance with state requirements for PASRR screenings, but R40's screening had not been completed at the time of the survey.
Failure to Monitor Ileostomy Site as Ordered
Penalty
Summary
The facility failed to adhere to physician orders by not monitoring a resident's ileostomy site every shift as required. The resident, who was admitted with an ileostomy and other medical conditions such as chronic obstructive pulmonary disease and bipolar disorder, had a care plan in place that included monitoring the stoma site for signs of infection or skin changes every shift. However, the Treatment Administration Record (TAR) for April 2025 showed multiple instances where the stoma site was not monitored as per the physician's order, including specific dates and shifts where the monitoring was missed. The resident expressed concerns about the lack of proper ileostomy care, and a nurse consultant confirmed that there were missed monitoring instances according to the TAR. The facility's policy on colostomy/ileostomy care requires documentation of care provided, including any signs of infection or skin issues, but this was not consistently followed. This deficiency was identified through observation, interview, and record review, highlighting a failure in the facility's compliance with the prescribed care plan for the resident.
Expired Milk Served to Resident
Penalty
Summary
The facility failed to ensure that residents are free from expired food, as evidenced by an incident involving a resident who received expired milk for breakfast. The resident, who has an intact cognitive status with a BIMS score of 15, reported receiving spoiled milk with an expiration date that had already passed. This incident was confirmed by the surveyor who inspected the milk carton and noted the expired date before it was discarded. The facility's policy requires staff to check expiration dates on food items before serving them to residents. However, in this case, the staff did not adhere to this policy, resulting in the resident receiving expired milk. The Dietary Manager explained the procedure for storing and checking milk, indicating that expired milk should be discarded and not served. Despite these procedures, the expired milk was still served to the resident, highlighting a lapse in the facility's adherence to its food safety protocols.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor and review antibiotic use for three residents, leading to a deficiency in antibiotic stewardship. The Infection Preventionist (IP), who had been in the role for approximately one month, acknowledged that there was no system in place to track and trend antibiotic use prior to her involvement. On April 9, 2025, the IP generated the antibiotic tracking/monitoring list for the first time with the help of other staff members. The IP noted that some residents were prescribed antibiotics without an end date, which could lead to potential complications such as compromised immune systems and resistance to antibiotics. The facility's antibiotic order report from April 2025 revealed that three residents had ongoing antibiotic prescriptions without specified end dates. One resident had multiple antibiotic eye drops prescribed since December 2024 and March 2025, another resident had a topical ointment prescribed since March 2025, and a third resident had been prescribed antibiotic tablets since April 2025. The facility's policy on antibiotic stewardship, dated April 2024, emphasized the importance of appropriate use, including specifying the duration of antibiotic treatment to improve patient outcomes and minimize resistance. However, the lack of a tracking system and oversight led to the deficiency in monitoring antibiotic use effectively.
Heating System Failure Due to Poor Maintenance and Water Leakage
Penalty
Summary
The facility failed to maintain its mechanical heating equipment, resulting in inadequate heating during cold temperatures, which affected all 144 residents. The Maintenance Director, V3, reported that the boiler control system was damaged due to water leakage from the ceiling, which originated from a rusted water heater tank. This damage led to one of the boilers being non-functional, preventing the facility from maintaining the required temperature of at least 75 degrees Fahrenheit. The heating issue was particularly problematic in the east area of the building on the 2nd floor, where residents experienced discomfort due to the cold. Interviews with staff and residents revealed that the heating problem persisted for several days, with residents needing additional blankets and some even moving away from windows to stay warm. The Director of Nursing, V2, was informed of the cold conditions by a nurse on January 2, 2025, but there was no temperature log for that day. The facility's temperature logs were incomplete, only covering January 3 to January 6, 2025, and did not include all necessary hours. The Maintenance Director admitted that there was no regular maintenance schedule for the heating system, which contributed to the problem. Observations of the facility's heating system showed significant rust and dirt on the boilers, with liquid dripping from the ceiling onto the equipment. The water heater tank, installed in 2012, was identified as the source of the leak, with its bottom severely rusted and continuously leaking. Despite the facility's Extreme Weather Temperature Policy, which requires regular inspections and maintenance of heating systems, these procedures were not followed, leading to the heating system's failure and the residents' discomfort.
Failure to Conduct Comprehensive Pre-Employment Background Checks
Penalty
Summary
The facility failed to perform comprehensive background checks on new employees before they began working, as required by the State Health Care Worker Registry. Specifically, the facility did not conduct searches on the six offender Website links on the State Health Care Worker registry for several employees, including a Housekeeping/Laundry/Maintenance Supervisor and three Certified Nursing Assistants. These employees were hired and started working without the necessary background checks being completed, which could potentially affect all residents at the facility. The Business Office Manager admitted to checking some registries only after being prompted by the surveyor, and there was no documentation of when the background checks were initiated. The Administrator acknowledged the importance of these checks to ensure the safety of residents and staff by preventing the hiring of individuals with criminal backgrounds. The personnel files reviewed lacked dates for the initiation of background checks, and several required registry searches were not performed, indicating a systemic failure in the facility's pre-employment screening process.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to report and investigate an allegation of misappropriation of property involving a resident's eyeglasses. The resident, who is cognitively intact with a BIMS score of 13 out of 15, reported that her designer eyeglasses were stolen from her room. Despite the resident's insistence and detailed description of the missing glasses, the facility did not take appropriate action to investigate or report the incident to the State Agency. The resident expressed frustration over the lack of response from the facility, stating that she had informed everyone about the missing glasses. Interviews with facility staff revealed a lack of communication and action regarding the resident's allegation. The LPN acknowledged being informed by the resident and notified the DON, but no further investigation or report was made. The DON, who was covering for the Administrator, claimed unawareness of the allegation and did not report it to the State Agency. The CNA stated that any allegations should be investigated and reported, but this was not done. The Administrator later acknowledged that the allegation should have been reported and investigated as misappropriation of property. The facility's records showed no report was submitted to the State Agency for this incident until after the surveyor's involvement.
Improper Documentation Practices in Resident's EMR
Penalty
Summary
The facility failed to ensure that a nurse followed established procedures for documentation in a resident's electronic medical record (EMR). This deficiency affected one resident, who had multiple diagnoses including hyperlipidemia, schizoaffective disorder, and legal blindness, among others. The resident was noted to have lethargy and abnormal vital signs, prompting a transfer to a local hospital. However, the documentation of this event was improperly recorded under the credentials of a nurse who did not assess the resident. The incident occurred when a Licensed Practical Nurse (LPN), identified as V9, used another LPN's (V8) electronic access to document in the resident's chart because V9 could not access the computer system. V8 admitted to allowing V9 to use her credentials, acknowledging that it was not professional practice and could lead to liability issues. V9 confirmed using V8's access and stated that she informed the Director of Nursing (DON) about the situation, although the DON denied being informed by V9. The facility's policies clearly state that only licensed personnel should document in a resident's medical record and that sharing access credentials is against professional practice. The Director of Nursing emphasized that nurses are educated not to share their passwords and should have contacted her or the Assistant Director of Nursing for assistance. The facility's documentation policies and job descriptions reinforce the importance of accurate and secure record-keeping, which was not adhered to in this case.
Inadequate Pest Control Measures Lead to Resident Complaints
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice and roaches in resident rooms and common areas. Multiple residents reported seeing mice in their rooms and common areas, with one resident noting that they had seen mice both during the day and at night. The presence of mouse droppings and live roaches was confirmed by housekeeping staff, who observed these pests in various locations, including under sinks and along baseboards. The facility's pest control measures were inadequate, as evidenced by the continued presence of pests despite the use of glue boards. The Maintenance Director acknowledged that the pest control company only treated common areas unless specifically directed to address resident rooms with known pest activity. However, there was a lack of communication and follow-up to ensure that pest control services were extended to affected resident rooms, even after evidence of pest activity was reported. The pest control company confirmed that they relied on the facility to inform them of specific areas requiring treatment. The facility's grievance binder and pest control service reports indicated that no specific resident rooms were treated for pests during the inspection period. This lack of targeted pest control intervention contributed to the ongoing pest issues, as residents continued to experience pest sightings and expressed concerns about living conditions.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Admiral At The Lake, The | 0.4 mi | ★★★★★ | 10 | 0 |
| Aperion Care Wesley | 0.4 mi | ★★★★★ | 5 | 0 |
| Sheridan Village Nrsg & Rhb | 0.6 mi | ★★★★★ | 1 | 0 |
| Selfhelp Home Of Chicago | 0.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Margate Park | 0.7 mi | ★★★★★ | 27 | 0 |
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