All American Vlge NRSG & RHB

In the surveyor’s words

From the most serious findings on record at All American Vlge NRSG & RHB, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 27, 2026

  Based 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. […]

• Actual harm, isolatedF600May 23, 2025

  Based 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. Findings include: 1. R1's Resident Face Sheet documents diagnoses of schizoaffective disorder, bipolar type; anxiety disorder; and bipolar disorder. R1's Care Plan documents R1 experiences delusions (8/22/2024). V12's (Psychiatric Rehabilitation Services Coordinator) progress note for R1, dated 1/16/2025 10:31 PM, documents R1 was involved in a physical altercation with co-peer. R1 displayed agitated and aggressive behavior with delusions. […]

• No harm, potential for more than minimal, widespreadF812Feb 5, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Apr 11, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF880Apr 11, 2025

  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. […]