AN INVESTIGATION OF AN "ALL-AMERICAN" NURSING HOME by brett david stewart

By Brett David Stewart (October 24, 2016)

The All American Nursing Home, a facility in the heart of Edgewater, is an establishment that has had repeated trends of uncleanliness and potential harm to residents for the last seven years. These trends are reflected in ‘surveys,’ or inspection reports filed by the Illinois Department of Health.

In inspections dating back to 2009, All American has been cited for an array of potential violations in regard to the facility’s cleanliness. In a 2010 case, inspectors reported mold, peeling paint, valves protruding from the floors, insects, garbage scattered in bedrooms, and more. There are many reports throughout the years that read very similarly to that 2010 inspection.

Throughout the country, Medicare rates nursing facilities on a scale of one to five stars. The more stars a home has, the better that home has fared on a scale that takes into consideration health inspections, the home’s staffing, and quality measures they have put in place. The All American Nursing Home is a two star facility.

With 144 licensed beds, All American is a for-profit, privatized nursing home where the entirety of the resident population is at the home on Medicaid. Due to the infrequent nature of inspections, the repeated issues on record at All American are very likely a small fraction of the facility’s day to day complications.

In 2011, another report was filed after the state found uncleanly care and habits of residents. One resident had sat in their own urine long enough for it to soak through several layers of clothing and sheets. Another would regularly defecate in a sheet, which the facility was aware of, and would clean the sheet in lieu of taking that resident to the bathroom.

In a 2014 case, the facility’s bathrooms were found in violation by the state. “The bathtub,” the report states, “was filled with standing, dirty water, containing hair and scum, even though the plug was not in.” That same tub did not have a privacy curtain, either, and the tiles in the bathroom were cracked.

In All American’s facility response to that report, they cited repairing each of the issues in the bathroom. In fact, the majority of their responses claim to have undergone repairs shortly after being inspected by the Department of Health. Yet, the same issues continue to arise.

Wendy Meltzer is the executive director of Illinois Citizens for Better Care, a leading advocacy group for nursing home residents. “They have a very large number of people with mental illness, most of them just shouldn’t be there,” Meltzer said in regard to All American. “My guess is that there is a certain amount of destruction which is greater than you would find in a facility that has people who are much frailer and older.”

Out of the 141 current residents at the All American Nursing Home, 49 of them are there for mental illness, the largest group of a single diagnosis. 96 of those 141 residents are between the ages of 18 and 59, making that the overwhelming age group at the facility.

Mary Claussen is the administrator of the All American Nursing Home, a position she has held for just over three years. “We feel that the star system is not always an accurate measure,” she said. “Facilities with more challenging residents, whether it be due to physical, psychological, or mental issues, will tend to score lower.”

In a 2014 report, residents claimed to be seeing mice “all over” the facility. Upon inspection, mice droppings were found in eleven different locations, many of which were accompanied by holes in the wall.

“All American has existed as a nursing home for over fifty years, and as with any facility, that sees wear and tear on a daily basis,” Claussen said. “I have a professional pest control company that inspects our building on a weekly basis and along with our daily rounds, we have no pests or rodents inside the facility.”

In regard to All American improving in the future, Claussen argues that “being hands on day in and day out” is the most important part of operating a nursing home. The facility has worked to improve and maintain cleanliness through daily rounds.

In February of 2016, the Department of Health filed an inspection report very similar to previous citations from years prior. “In the men’s bathroom, there was a black substance permanently stained on different areas of the mirror,” according to the report.

“In the fourth floor dirty utility room, there was a mop bucket with dirty water,” the report further stated as the inspector explored the facility. “Across from the elevator, the partition intended to enclose a large air conditioner was not secured to the wall… leaving metal stub and drywall screw tips exposed.” Above this, ceiling tiles were sagging down half a foot.

Much like the report filed six years earlier in 2010 for the protruding valves, peeling paint, and garbage, the facility did respond with a laundry list of cited repairs. Many of these repairs, however, were for nearly identical items to previous issues: sinks, bathtubs, baseboards, paint, and more.

Outside of repeated cleanliness violations, the All American Nursing Home has had complications with the safety of their residents. In 2010, a state inspection reported that the facility had failed to adequately monitor two residents, a man and a woman.

The male resident was “an identified offender with a history of aggravated criminal sexual assault and domestic battery.” The Illinois Department of Public Health deemed the man “a moderate risk and a sex offender,” which would entail All American keeping “closer supervision and more frequent observation” on the resident.

“I was mopping the floor by the day room,” an employee said. “All of a sudden I saw a naked woman… I was shocked she was nude. When asked, she said the resident was trying to molest her… She said he was trying to sexually abuse her.”

At All American, the fourth floor is designated for men only. “We keep them, females, off to try to prevent them from being sexually harassed,” a nurse said about the floor. In this alleged sexual assault, however, the woman was found on the fourth floor.

In All American’s required facility response, they outlined no specific changes or plans of correction to prevent future incidents. Instead, the response stated the two residents no longer resided at the facility and that other residents will be adequately supervised.

In yet another case in 2010, a hard of hearing resident was left unattended in All American’s lobby. They wandered from the building at 11:30 am in the morning and were not found by the police until 2:00 am the next day. According to nurses’ notes that the state inspected, All American did not report the resident missing until 4:00 pm.

The Illinois Department of Public Health can fine nursing homes like All American when they are found in violation of their standards. Since 2007, All American has been fined four times. In contrast, the inspection reports readily available for the facility since 2009 number beyond 40.

In each fine, All American paid far less than the original assessment by the state. In 2007, they were fined $5,000 for failure to maintain a sanitary kitchen due to lack of handwashing and gloves. At the hearing for the fine, which didn’t occur until 2008, it was reduced to $1,200.

In 2011, a resident threatened another resident bodily harm, throwing a trash can at a roommate. All American was assessed for a fine of $12,500. Upon the hearing, that fine was reduced to an undisclosed amount.

Similarly, that same year All American was also assessed a $16,250 fine for failure to safeguard medical records. Nurses would leave charts unattended, sometimes resulting in them being lost. The final reduction of that fine isn’t readily available to the public, either.

The fourth fine All American was issued was in 2007, and again, was reduced upon a hearing. The cause and the reduction of the fine have not been filed by All American to be made readily available for the public.

The All American Nursing Home is privately owned by Howard and Deborah Wengrow and Sarah and Jeffrey Webster. Each person owns 25 percent of the home. Howard Wengrow has ownership in seven other homes, none of which are above three stars. Jeffrey Webster has ownership in five other homes, all of which Wengrow also has a stake in.

Since All American is a nursing home occupied entirely by Medicaid residents, the home is funded by the government, and indirectly, taxpayers. In the home’s financial disclosures in 2015, they cited over $60,000 of “other” costs. Despite being required to specify these costs, All American did not.

In addition to the “other” costs, All American Nursing Home had just over $5,000 listed in political action committee (PAC) donations. The specific candidates or causes that All American donated money to unclear, but is not uncommon for nursing homes to do so.

From the beginning of 2015 throughout 2016, All American Nursing Home’s complaint investigations by the state have decreased noticeably in contrast to previous years. There have been five complaint investigations in 2016, four of which the home was found in compliance with.

The investigation in which All American was found at fault was the aforementioned report in February where the home was required to make an array of repairs. Each subsequent report in 2016 was found in compliance, including the most recent in September.

The All American Nursing Home has had systemic issues of cleanliness and resident mismanagement for as long as their investigation reports are readily available for records dating back to 2009. Reports filed in 2010 are similar to those in 2014, which are similar to those filed this year in 2016.

With all residents on Medicaid, it’s highly likely that they did not choose to be at All American, but rather, were delegated to the home by a nearby hospital. Unlike some nursing homes, All American’s residents are comparatively young, making it, in some ways, as much of a homeless shelter as it is a nursing home.

These trending issues are highlighted more poignantly upon reading inspection reports that detail the daily life of the residents at All American. In a 2010 investigation, the state reported aimless and seemingly depressed residents that were unengaged from all activities.

“None of the residents were engaged or encouraged by the staff to become engaged,” the state report said. One resident was found asleep “bent over in their rolling walker,” and more residents were found “with heads lying down on tables,” sleeping in the social areas.

When the investigator entered the dining room that day, they found twenty-nine residents ignoring all activities, music, and social engagement. The staff, according to a nurse, “were aware that not all residents were engaged in the morning’s activities.”

Despite All American having less incident reports each year, it remains a two star home. The reports that are filed more than often echo their predecessors, however, proving there are trending issues that need to be addressed at All American, even now. For the home to improve their overall rating from Medicare, they'd likely have to increase their staff and consistently utilize the recommendations of health inspections to create a better living space for their residents.

Photos are for illustrative purposes courtesy of Ulrich Joho and Sima Dimitric.

Created By
Brett Stewart
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