Aperion Care Westchester

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting an allegation of physical abuse to the Illinois Department of Public Health's Regional Office for one out of three residents reviewed for abuse in a total sample of nine. Findings Include: R4 is a [AGE] year old with the following diagnosis: spastic quadriplegic cerebral palsy, chronic kidney disease, heart failure, mild cognitive impairment, and contracture of the right hand and wrist. On 5/27/26 at 12:52PM, R4 was able to state name and birthdate correctly. R4 stated the date was 5/20/16 and R4 was in [NAME], IL. When asked if R4 has any issues or concerns in the facility, R4 stated no. When asked if R4 felt safe in the facility, R4 stated no. R4 reported a lady tried to drown R4 in the shower last week. R4 was unsure of the exact date and was unable to name the CNA. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call lights were placed/secured within reach, failed to ensure that essential equipment was functioning, and failed to supervise an at risk for falls resident while outside smoking, This failure affects three of three residents (R1, R3, R4) reviewed for falls on the sample of four.

Inspectors wroteBased on interviews and record review, the facility failed to follow policy procedures, failed to clarify physician orders, failed to ensure that the required rate for IV (Intravenous) infusion was ordered (prior to administration) and failed to document the rate of IV infusion for one of four residents (R2) reviewed for change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Medication Administration Policy by failing to administer medications in a timely manner. This applies to four of 15 residents (R2, R7, R4 and R5) reviewed for medication administration in a sample of 15.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to wear gloves while touching food while taking food temperatures before lunch was served, failed to wear beard nets and properly wear hair nets while in the kitchen area. This failure has the potential to affect all residents receiving meals in this facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have an effective pest control program and ensure the kitchen area was free from flying insects. This failure affects all residents that receive meals in this facility.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to follow its policies and procedure to ensure resident received incontinence care at least every two hours or as needed, and failed to ensure a resident was positioned per physician order for feeding. This affected four residents (R103, R48, R61, and R113) reviewed for activities of daily living assisted by staff on the sample of 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the medication storage policy by having opened undated medication and expired medication of the medication cart. This affected four of four residents (R3, R74, R113 and R95) reviewed for labelling and storage in the sample of 45. Findings Include:R3 was diagnosis with Dementia Mellitus. R3's physician order dated [DATE] documents: Insulin lispro solution - Inject as per sliding scale (start date [DATE]). R74's physician order dated [DATE] documents: Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in right eye eve (start date [DATE])On [DATE] at 12:18pm, during medication cart inspection with V31 (nurse), R3 was observed with lispro insulin dispensed date [DATE] open and not dated. V31 said, R3's insulin was used, open and not dated. [...]

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to ensure staff wear gloves when handling soiled laundry and failed to follow the facility failed to follow its glucose testing policy by not placing a barrier between a used glucometer and the medication cart, and failed to perform hand hygiene and clean the glucometer while taking blood glucose levels. This affected two of two residents ( R7, R3) reviewed for infection control practices and residents residing on the 200 hall. Findings Include:

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner by providing timely toileting assistance. This failure affected three residents (R48, R61, and R113) reviewed for resident rights on the sample of 45.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately incorporate a resident's directive for life sustaining treatment into the medical record. This failure affected one resident (R9) reviewed for advance directives in the sample of 45.

Inspectors wroteBased on observations and interviews, the facility failed to provide privacy while providing a bed bath. This affected one resident (R48) reviewed for privacy while receiving direct care on the sample of 45.

Inspectors wroteBased on observation and interview the facility failed to ensure the resident room was clean and sanitary for one of 8 residents (R59) in total sample of 45 reviewed for clean homelike environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to have an appropriate diagnosis for the use of antipsychotic medications, failed to identify a specific behavior for the use of an antipsychotic medication. This failure affected two residents (R8 and R9) reviewed for unnecessary medications on the sample of 45.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow orders and obtain a urine analysis ordered on 4/6/25 for a resident with a history of urinary tract infections This affected one resident (R22) reviewed for physician orders on the sample of 45.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure enteral feeding and tubing is properly labeled and dated before administration, failed to ensure tubing was in correct position in the feeding pump for one resident (R113) reviewed for enteral feedings on the sample of 45.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure oxygen tubing changed and dated weekly. This failure affected two residents (21 and R48) reviewed for respiratory care on the sample of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light was functioning for a dependent resident R2 reviewed for functioning call light system in total sample of 45 residents.

Inspectors wroteBased on observation and interview the facility failed to post Nurse Staffing Data in a prominent area available for residents and visitors. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the state inspections are available for the residents to read without having to ask the staff for them. This affects 4 of 4 residents (R91, R40, R111, R23) in the sample of 45 resident reviewed for residents' rights for state inspection.

Inspectors wroteBased on observation and interview, the facility failed to ensure that resident care equipment was clean and in good, repaired condition and properly stored by not comingling with functional ones to prevent accidental use for prevention of infection. This failure has the potential to affect R1, R3, R4, R5 and R6 reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to develop an effective plan to prevent and/or reduce the risk of falling for a resident identified to at high risk for falls, and failed to follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This affected 6 of 6 residents (R1, R2, R4, R5, R6 and R7) reviewed for falls and fall risk assessments. This failure resulted in R1 having multiple falls R1 had a fall in his room on 8/27/24 at 7:45AM, and then another fall same day at 1:47PM in the dining room that resulted laceration in left side eye brow forehead requiring sutures on 8/27/24 and third fall on 9/12/24 in the dining room that resulted in left eyebrow laceration re-opening. Findings Include: R1 is [AGE] year old resident and still currently in the facility. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy and prevent an incident of resident to resident physical assault. This affected two of three residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 attacking and hitting R3 with a cane unprovoked.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered; failed to ensure medication is available during medication administration; and failed to follow manufacturer's guidelines in insulin pen administration. There were 27 opportunities with eight errors resulting in a 29.63% medication error rate. The errors involved four (R46, R63, R82 and R86) of 10 residents in the sample of 47 reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedures for infection control by not ensuring a catheter urinary drainage bag was protected from contaminated surfaces for a resident with a history of UTI's (Urinary Tract Infection); failed to date nasal cannulas and humidifier bottles for residents receiving oxygen; and failed to perform hand hygiene or wear personal protective equipment when providing care to residents on enhanced barrier precautions. This failure applied to five of five residents (R40, R46, R64, R86, and R296) reviewed for infection control.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse for one of two residents (R73) reviewed for abuse in a total sample of 47.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for Urinary Catheter Care by not ensuring a catheter urinary drainage bag was emptied timely for a resident with a history of UTI's (Urinary Tract Infections). This failure applies to one of one residents (R86) reviewed for catheters and UTI's (Urinary Tract Infections).

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing coverage on specific days and shifts ensuring adequate resident care and assistance for four (R6, R7, R10 and R11) of four residents reviewed for staffing. This deficiency also has the potential to affect all the 95 residents currently residing in the facility.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide necessary incontinence care in a timely manner on residents who are dependent on staff for performing their activities of daily living. This deficiency affects four (R6, R7, R10 and R11) of four residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needs extensive assistance with activities of daily living (ADLs) received incontinence care in a timely manner for 1 of 5 residents (R2) reviewed for ADLs in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound dressing changes were performed as ordered by the physician for 2 of 3 residents (R1 and R6) reviewed for quality of care in the sample of 9.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident rooms in a clean and sanitary manner for 4 residents R1, R2, R4, R6 reviewed for clean, comfortable, homelike environment in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care, nail care, and oral hygiene for 3 of 7 residents (R4, R3, R2) reviewed for activities of daily living in the sample of 21.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect a confused and vulnerable resident (R1) from being physically abused by a staff member and failed to follow their abuse policy by not preventing staff to resident physical abuse. This failure resulted in R1 obtaining facial injuries with noted scratches with active bleeding, swelling, pain and bruising that required the resident to be transferred emergently to a local hospital for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform a physician of abnormal labs prior to a resident's change of condition of 4/03/2023 for one of thirty residents (R3) in the sample. This failure resulted in R3 having to be hospitalized due to acute hypoxemic respiratory failure, seizures, and hypernatremia. Findings Include: R3 is a [AGE] year old female who was originally admitted to the building on 7/26/2012 and still currently resides in the facility. R3 has multiple diagnoses including but not limited to the following: epilepsy, vitamin D deficiency, multiple sclerosis, severe protein calorie malnutrition, dementia, hypernatremia, hypokalemia, pressure inducted deep tissue damage, and gastrostomy. Facility lab report dated 4/3/23 shows in part but not limited to the following: blood urea nitrogen (BUN): 30 (High) and Sodium (Na): [...]