All American Vlge Nrsg & Rhb

Inspectors wroteBased on interview and record review, the facility failed to affirm the right of their residents to be free from verbal and physical abuse. This failure affected two (R2, R4) out of six residents reviewed for abuse. The deficient practice resulted in actual harm when R4 sustained a left eye injury. Findings Include:R4's clinical records show an admission date of 9/26/24 and discharged on 3/18/26, with included diagnoses but not limited to bipolar disorder and anxiety disorder. R4's Minimum Data Set (MDS) assessment, dated 1/1/26, shows a BIMS (Brief Interview for Mental Status) of 15, which means R4 was cognitively intact and required setup help to supervision with activities of daily living (ADLs). R4's progress notes, dated 3/12/26 at 3:21 PM documented by V8 (Licensed Practical Nurse/LPN), reads: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure walk-in cooler, refrigerator (Reach In cooler) and freezer maintained a daily log tracking of temperatures; failed to maintain refrigerated foods within normal ranges; failed to label foods with open and use by dates; and failed to discard foods with expired dates. This has the potential to affect all residents residing in the facility. Upon initial kitchen observation at 9:15 am, refrigerator, freezer, and walk-in cooler (walk-in cooler tracking log on a clip board) had a January Tracking log affixed to the outside doors; refrigerated foods with no open or use by date; refrigerated foods with expired use by dates; walk-in cooler with an out of range temperature; and foods temperature measuring at warmer temperatures than normal range. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the linen chute was secured to prevent unauthorized access. This failure has the potential to affect all 47 residents on the third-floor unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medications for four residents (R61, R87, R96 and R124), failed to label multiuse medications for six residents (R9, R23, R55, R106, R132, and R133),and failed to monitor the temperature of the medication refrigerator that included medications for three residents (R30, R102 and R12. This failure affected 13 residents in a total sample of 50 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for two residents (R7, R85) was within reach. This failure affected 2 residents out of a sample size of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a discharge plan that reflects the residents post discharge needs, goals, and treatment preferences. This failure effected one (R70) in a sample size of 50 residents reviewed for discharges.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident (R71) who has a serious mental illness was referred to the appropriate state agency for a Level 1 PASRR (Pre-admission Screening and Resident Review) evaluation and failed to refer one resident (R12) to the appropriate State Agency for evaluation after being diagnosed with a serious mental illness. This deficient practice affected two residents (R12 and R71) in a total sample size of 50 residents. Findings Include: 1. On 2/2/2026 at 10:43 am, R12's Preadmission Screening and Resident Review (PASRR) I and II were not noted in R12's electronic health record. R12's PASRR Level I and Level II were requested from V4 (Admissions Director/Business Office Manager). On 2/4/2026 at 11:38 am, V4 (Admissio. Director/Business Office Manager) stated R12 has a serious mental health condition of schizoaffective disorder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the development of a care plan focused on a serious mental health illness to maintain proper disease management and continuance of care. This failure affected 1 of 1 resident (R12) in the sample of 50. R12's Face Sheet, dated 2/4/2026, documents a diagnosis of but not limited to for schizoaffective disorder on 3/2020. R12's Minimum Data Set Section C documents a BIMS (Brief Mental Interview Status) Score of a 15, which is indicative of an intact cognition. R12's care plan, dated 11/18/2025, does not document a focus for a severe mental illness of schizoaffective disorder. On 2/4/2026 at 11:51 am, V6 (Social Services Director) stated, (R12) should have a care plan for schizoaffective disorders to manage the condition effectively. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide necessary foot care, treatment, or professional referrals to maintain skin integrity on the foot. This failure affects one resident(R70) in a sample size of 50 reviewed for podiatric/foot care. R70's face sheet, dated 2/4/2026, documents R70 was admitted to the facility on [DATE] with diagnoses of Diabetes mellitus, multiple myeloma, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, and gastro esophageal reflux disease. R70's Minimal Data Set section C cognitive patterns, dated 12/11/2025, documents R70 has a Brief Interview for Mental Status score of 15, which means R70 is cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents had a privacy curtain that extended around the bed. This failure affected one resident (R77) in the total sample of 50 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to include the required elements (date and census) on the daily nursing staffing post. This failure affected all the 134 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to keep three residents (R2, R3, R4) free from abuse for three of four residents reviewed for abuse. This failure resulted in R2 losing a dental implant and a tooth, R3 sustaining an upper lip laceration, and R4 complaining of headache after being kicked to the head.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.