Aperion Care Niles

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the expired multi-dose vial of tuberculin test was removed and discarded affecting 44 residents currently residing on 2nd floor. Findings Include: On 5/26/2026 at 6:48 AM on 2nd floor medication refrigerator a multi dose vial of tuberculin test with date expired on 5/11/2026. On 5/26/2026 at 6:51 AM V4 (Licensed Practical Nurse) said expired medications should be discarded and not kept in the refrigerator. The tuberculin multi dose vial has an opened date of 4/12/2026 and date expired of 5/11/2026. Vial should be removed and discarded. On 5/27/2026 at 9:30 AM V2 (Director of Nursing) stated all expired medications should be removed, discarded, and not kept in the refrigerator. Policy and ProcedurePolicy Title: Storage of Medications, no datePolicy: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control practices during medication administration affecting 4 of 7 residents (R39, R8, R77, R72) observed for medication pass for total sample of 19. Findings Include:On 5/26/2026 at 8:05 AM - 9:30 AM during medication administration V6 (Registered Nurse), V7 (Licensed Practical Nurse), and V8 (Registered Nurse) all failed to clean and disinfect their personal blood pressure (BP) machine between each residents used. V6 checked and measured BP for R39 prior to medication administration then proceeded to R8 also measured BP using the same blood pressure machine without cleaning and disinfecting. V7 measured BP for R72 and did not clean and disinfect BP equipment after using. V8 measured blood pressure for R77, cleaned the BP machine but did not disinfect according to manufacturer's recommendation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a dignity cover for a indwelling urinary catheter for one of two residents (R72) reviewed for indwelling urinary catheter in a sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a person-centered comprehensive care plan was implemented for one of three residents (R72) reviewed for care plan interventions in a sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to implement the restorative program recommendation for one (R77) of six residents reviewed for restorative program in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility guidelines in gastrostomy management care for one (R1) resident in the sample of 19 reviewed for gastrostomy management.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct daily refrigerator temperature checks inside the resident's room to ensure proper temperature and food safety. This deficiency affects two residents (R10 and R84) in the sample of 19 reviewed for Resident safe food storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper hot water temperatures were maintained in one shower room (Second Floor East Wing). This failure has the potential to affect 22 residents that currently reside on the Second Floor East Wing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for safe and sanitary food by not ensuring resident's personal refrigerator temperatures were consistently monitored and accurately documented, failed to ensure that food stored in resident's personal refrigerators were stored and labeled properly, and failed to ensure that staff remove old and expired food items from resident's refrigerators. These failures affected four (R23, R40, R56 ad R80) of four residents reviewed for food safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use a low air loss mattress in accordance with manufacturer guidelines, for a resident with a facility acquired, Stage 4 pressure ulcer. This failure applied to one (R3) of three residents reviewed for pressure ulcers in a sample of 33 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for psychotropic medication administration by not ensuring a gradual dose reduction evaluation was performed quarterly for a resident receiving psychotropic medications. This failure applied to one (R82) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to follow R1's plan of care to provide supervision with meals (eating), ensure R1's assistive mobility device was within reach and ensure R1 was wearing appropriate footwear. R1 who is high risk for falls, was left in the room unsupervised. R1 had a fall incident on 11/13/24 that resulted in subdural hematoma. This past noncompliance occurred from 11/13/24 to 11/15/24.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively monitor a newly admitted resident and follow the facility practice of leaving doors open for residents identified to be at risk for falls. This affected one of three residents (R1) reviewed for safety and monitoring. This failure resulted in R1 being found on the floor. R1 was sent to the local hospital and treated for a laceration that required 2 staples, and 6 sutures in frontal scalp laceration and 1 staple left superior lateral scalp laceration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. wear a hair restraint to cover a beard while in the kitchen, 2. ensure hand soap was available at the hand washing sink in the kitchen, 3. maintain sanitizing solution buckets at 200 ppm (parts per million) of Quaternary Ammonium solution for sanitizing kitchen surfaces and dishes in the three compartment sink, 4. maintain sanitizing solution in the low temperature chemical sanitizing dishwasher at 50-100 ppm (parts per million) of Chlorine solution for sanitizing kitchen dishware and utensils, 5. cover, date, and label prepared desserts in the refrigerator, and a bag of fish while stored in the freezer, 6. ensure staff are properly trained how to clean the kitchen, 7. perform hand hygiene prior to putting on gloves to prepare food and maintain infection control, 8. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide feeding assistance in a dignified manner for 5 (R18, R33, R37, R44, R71) out of 5 residents reviewed for dignity in the sample of 41.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow standard infection control practices by not washing hands and not changing gloves while performing dressing change for 1 (R41) of 1 resident reviewed for pressure injury in the sample of 41. This failure may affect 10 resident who currently require dressing changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly administer physician ordered continuous oxygen to an immunocompromised resident dependent on supplemental oxygen and monitor oxygen saturation level for 1 (R290) of 1 resident reviewed for oxygen therapy in sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nutrition, and follow dietary order for 2 (R18, R44) of 5 reviewed for nutrition in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and immediately remove the alleged staff from resident care. This affected one of three (R1) residents reviewed for abuse policy. Findings Include: On 1/23/24 at 11:45AM, R1 stated that R1 went to the third floor looking for someone who can assist him to look for his nurse. R1 went to the back by the med room and knocked, a male voice from the inside answer saying he is not the nurse but will look for my nurse. I just want to make sure, so I know who I was talking to, so I opened the med room door and found V7 (Registered Nurse/RN) inside. V7 stood up from a chair, kneed me with his right knee to my left knee and put his hands on my shoulder and pushed me away from the med room. I told him, take your hands off me. Stated that there were no other staff or residents witnessed the incident. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to follow its abuse policy and immediately report an allegation of physical abuse to the regulatory agency within two hours. This affected one of three (R1) residents reviewed for reporting allegation of abuse. Findings Include: On 1/23/24 at11:45AM, R1 stated that R1 reported to V1 (Administrator) the allegation of physical abuse by V7 (Registered Nurse/RN) to R1 via phone around 4 or 5am on 1/3/24. On the same morning, V1 came and talked to R1 in person. They also called the Police Department to report the incident. Facility reported incident report confirmation, reads that the incident was reported to regulatory agency on 1/3/24 at 11:39 AM. On 1/24/24 at 10:30AM, V1 stated that he was made aware by R1 about the abuse allegation probably around 5am on 1/3/24 via phone. The nurse called V1 and gave the phone to R1. [...]