Health inspection·August 5, 2024

F 0925 still be around. R5 stated R5 has never seen anyone from the pest control company in R5's room. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Many 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All American Vlge Nrsg & Rhb 5448 North Broadway Street Chicago, IL 60640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146198 If continuation sheet Page 3 of 3