Aperion Care Elgin

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident attended infectious disease (ID) follow-up appointments, documenting and notify the attending the ID specialist of the missed appointment, resident refusal of care and the resident's discharge from the facility. This applies to 1 of 3 (R6) residents reviewed for care regarding active infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent the verbal/mental abuse of a resident. This applies to 1 of 3 (R1) reviewed for abuse in a sample of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen and during meal service in the dining room. This applies to all 84 residents that received foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to follow their policies for handling soiled laundry, contact isolation, hand hygiene during provisions of care, and cleaning medical devices between residents. This applies to all 86 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents requiring moderate assistance with grooming. This applies to 1 of 5 residents (R75) reviewed for ADLs (Activities of Daily Living) in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to quarterly assess a resident's nutritional status. This applies to 1 of 4 residents (R63) reviewed for nutrition in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and care for a midline peripheral intravenous catheter. This applies to 1 of 1 residents (R48) reviewed for intravenous catheters in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to report a suspicion of a crime to law enforcement and the survey agency in a timely manner in accordance to the facility policy. This applies to 1 of 3 (R1) residents reviewed for incidents in sample of 5.

Inspectors wroteBased on interview and record review the facility failed to investigate an incident of a suspicion of a crime in accordance with their policy. This applies to 1 of 3 (R1) residents reviewed for incidents in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to hold care plan conferences with residents and their representatives and failed to invite residents and their representatives to participate in the care planning process. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for administration in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to schedule neuropsychological testing for a resident as ordered by the neurology physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to schedule an ophthalmology appointment for a resident as ordered by the neurologist. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received an MRI (Magnetic Resonance Imaging) as ordered by the neurologist. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation arrangements were made for a resident with a scheduled physician follow-up appointment. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure emergency sized tracheostomy tubes for a resident (R1) who required tracheostomy care were available. This failure resulted in R1 experiencing acute respiratory distress and requiring an emergency hospitalization for acute respiratory failure. R1 had to be connected to mechanical ventilation for emergency respiratory support. The facility also failed to ensure licensed nurses were trained on how to change tracheostomy tubes and to dispose of expired tracheostomy inner cannulas. This applies to 1 of 3 residents (R1) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired food items from the dry storage. The facility also failed to follow its dishwashing machine operation guidelines by not checking the dishwashing machine before its first use to ensure sanitization. This applies to all 87 residents consuming food from the kitchen. The Findings Include: On 4/30/24 at 10:12 AM, during an initial tour of the kitchen, the kitchen dry storage was observed with two one-gallon Worcestershire sauces used by the date of 12/13/2022. On 4/30/24 at 10:15 AM, V11 (Dietary Manager) stated that the expired sauce shouldn't be there and that he would discard it. The facility presented food storage guidelines and procedural Manual (2020) document: c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for self-administration and storage of medication, as well as notifying and ordering medications for residents who were self-administering. The facility also failed to ensure residents took their medications during medication pass. This applies to 4 of 4 residents (R12, R25, R34, R71) reviewed for administration and storage of medications in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and care plan residents that smoke per facility policy. The facility also failed to ensure smoking materials were kept in the designated secure location. This applies to 5 of 9 residents (R46, R62, R71, R74, and R387) reviewed for safe smoking in the sample of 26. The Findings Include: 1. R46 is a [AGE] year-old male admitted on [DATE] with moderately impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. R46 was observed on 4/30/24 at 10:45 AM in his room with an opened pack of cigarettes and matches on the bedside table. R46 stated, I have cigarettes and matches with me to go for smoking. I may go for a smoke after lunch. Record review on smoking safety risk assessment for R46 dated 1/15/24 document: All smoking materials will be kept locked in the facility designated area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify the counting logs accuracy for residents with controlled medications (R28, R47, and R52) and failed to dispose of controlled medications (R43) per facility policy. This applies to 4 out of 4 (R28, R47, R43, and R52) residents in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care to a resident dependent on toileting and failed to keep indwelling catheter drainage bag off the floor. This applies to 2 out of 2 residents (R46 and R48) observed for incontinence care and indwelling catheter care in a sample of 26. 1. On 4/30/2024 at 11:29 PM, R48 had a strong smell of urine. On 4/30/2024 at 11:32 AM, skin check with V13 (CNA-Certified Nurse Assistant) showed R48's incontinent brief was soaked with urine. R48's shirt and bed pad were soaked with urine. R48's coccyx was observed to be red. V13 provided incontinence care but did not apply barrier cream. On 5/2/2024 at 11:22 AM, V2 (DON-Director of Nursing) said she expects staff to check for incontinence care frequently at least every two hours. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its oxygen and respiratory equipment changing/cleaning policy by not changing respiratory tubing and humidifier on weekly basis and not storing nasal cannula and nebulizer mask in a plastic bag with zip loc. This applies to 3 of 3 residents reviewed (R10, R40, R46) for respiratory care in a sample of 26. The Findings Include: 1. R46 is a [AGE] year-old male admitted on [DATE] with moderately impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. On 4/30/24 at 10:45 AM, R46 was observed on his bed with his nasal cannula on the floor with no date/label. The humidifier was observed to be dirty and had no date/label. On 4/30/24 at 10:45 AM, R46 stated, They don't care about the tubing change. I filled the humidifier water chamber a couple of times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document behaviors; and failed to develop and update plan of cares with interventions for residents (R1 and R61) with known behaviors related to mental disorders. This applies to 2 out of 2 residents (R1, R61) reviewed for behaviors in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% error rate. This applies to 2 out of 2 (R29, R77) residents in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer the correct doses of insulin medications to residents (R29 and R77) and scheduled pain medication to a resident (R26). This applies to 3 out of 3 (R26, R29, R77) residents in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications. This applies to 2 of 2 (R34, R47) residents in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with substance use disorder was safe for independent community access after being hit by a car the previous day while out in the community. This failure resulted in R2 being found on the side of the road by a bystander and requiring hospitalization. Hospital records show R2 had fractures of the left fourth through 12th ribs, and an elevated blood alcohol level. This applies to 1 of 3 residents (R2) reviewed for accidents in the sample of 6. The Immediate Jeopardy began on March 24, 2024 at 9:14 AM when R2 signed out of the facility without being assessed to be safe for independent community access after presenting to the nurse with alcohol on his breath, and after being hit by a car the previous day while out on community pass. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This applies to 2 of 3 residents (R8 and R9) reviewed for abuse in the sample of 11

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve palatable meals to the facility residents. This applies to all 91 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner. This applies to all 91 residents residing at the facility receiving oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management program for prevention of legionella growth. The facility also failed to follow their policy for hand hygiene during R69 and R88's wound care. This applies to all 91 residents residing in the facility. The Resident Census and Conditions of Residents report dated June 5, 2023, shows the facility census as 91 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail, facial care and transfer for toilet needs to residents needing assistance with ADLs (Activities of Daily Living). This applies to 4 of 8 (R16, R25, R19 and R76) residents reviewed for ADL in the sample of 20.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to follow physician orders for wound treatment and failed to provide pressure redistribution wheelchair cushion for a facility acquired pressure ulcer per physician orders. This applies to 1 of 5 residents (R14) reviewed for pressure ulcer prevention and treatment in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to implement fall prevention interventions for R54 when providing personal care. This applies to 1 (R54) of 3 residents reviewed for accidents and supervision in the sample of 20. The Physician Order Sheet (POS), printed 6/7/23, shows R54's diagnoses included dysthymic disorder, dysarthria, anarthria, psychosis, depressive disorder, adjustment disorder, anxiety disorder, agoraphobia, osteoarthritis, and history of falling. Resident Fall Care Plan, initiated on 12/2021 and revised 2/28/23, shows R54 fell on [DATE] and interventions implemented at the time of his 12/16/22 fall included providing two staff to assist him with ADLs (Activities of Daily Living). The care plan shows R54 also fell on 2/23/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician-ordered weight loss prevention interventions for a resident who experienced significant weight losses. This applies to 1 of 2 residents (R54) reviewed for weight loss in the sample of 20.

Inspectors wroteBased on observation and interview, the facility failed to provide a private area for the Resident Council to meet without staff proximity to the meeting. This applies to all the residents in the facility.