Avenora Elmhurst

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate supervision to a resident with impaired upper extremity range of motion. This failure resulted in the resident spilling hot oatmeal on self and acquiring a burn. The facility also failed to follow their policy to ensure that immediate treatment procedures are followed after a burn incident. This applies to 1 of 1 resident (R1) reviewed for accidents and supervision in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a plan of care to prevent the development of a pressure ulcer for a resident who was identified as being at risk for pressure ulcers. This failure resulted in R6 developing an infected eschar covered left heal pressure ulcer. This failure applies to 1 of 2 residents (R6) reviewed for pressure ulcers in the sample of 15. Findings Include:R6's admission record showed he was admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and aphasia. R6's Minimum Data Set, dated [DATE] showed that R6 was dependent on the facility for assistance with all functional abilities. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all the required members of the QA (Quality Assurance) Committee were in attendance at the meetings over the past year in accordance with their policy. This has the potential to apply to all 42 residents who reside in the facility as identified on form 671 completed by V3 (owner, former Administrator) on January 5, 2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a water management program according to their policy and failed to follow standard infection control practices related to hand hygiene and gloving during provisions of incontinence care, medication administration and wound care. The facility also failed to ensure staff are wearing full personal protective equipment (PPE) when providing care for residents who are on Enhance Barrier Precaution (EBP). This applies to all 42 residents in the facility. Findings Include:F880 Form CMS (Centers for Medicare and Medicaid Services)-671 (Long Term Care facility application for Medicare and Medicaid) dated January 5, 2026, showed the facility had a total census of 42 residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hygiene/grooming care for residents who require assistance with activities of daily living (ADL) care. This applies to 4 of 6 residents (R20, R30, R36, R38) reviewed for ADL care in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and label insulin and eye drop medications when it was opened to determine expiration of the medications and failed to discard expired insulin. This applies to 6 of 6 residents (R3, R12, R18, R26, R42, R45) reviewed for medication storage in the sample of 15.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop care plan interventions for a resident that refuses personal care and meals. This failure applies to 1 of 3 (R30) residents reviewed for care planning in a total sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a recommended device for residents with limited range of motion to prevent further contracture. This applies to 2 of 3 residents (R12, R39) reviewed for limited range of motion in the sample of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to manage a residents pain by not administering analgesic medication as prescribed. This applies to 1 of 1 resident (R9) reviewed for pain management in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to provide written documentation of residents' transfer or discharge from the facility. This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for inappropriate discharges in a sample of 4.

Inspectors wroteBased on interview and record review the facility staff failed to immediately notify the nurse when a resident had a change in condition and could no longer stand and/or bear weight on her leg after a transfer. This resulted in a delay in care and treatment for R1 who had a hip dislocation. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a pressure injury prior to becoming unstageable, failed to implement offloading, and failed to develop and implement a care plan after the development of pressure ulcers for 1 of 5 residents (R14) reviewed for pressure in the sample of 16. This failure resulted in R14 developing two unstageable pressure injuries, one to each heel.

Inspectors wroteBased on interview and record review, the facility failed to identify a significant weight loss, failed to notify a resident's physician and/or dietician for a significant weight loss, failed to develop care plan interventions to address a resident's significant weight loss. These failures apply to 1 of 2 residents (R27) reviewed for nutrition in the sample of 16. This resulted in R27 sustaining a 5.87% weight loss in 1 week.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen utensils were stored correctly and change gloves while handling equipment/utensils to prevent cross contamination. This failure has the potential to affect all 33 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have policy and procedures in place for residents (R28, R186, & R10) on enhanced barrier precautions. The facility failed to have a policy or plan for legionella. This failure has the potential to affect all 33 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen freezer in a safe operating condition This failure affects all 33 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat two residents (R13,R20) with dignity. This applies to 2 residents outside of the sample reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care to 1 resident (R26) outside of the sample reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 residents (R27 & R26) were free from restraints. This applies to 1 of 1 residents (R27) reviewed for restraints in the sample of 16 and 1 resident (R26) outside of the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to use a gait belt to transfer a resident (R16) and failed to provide supervision during mealtimes for a resident with a diagnosis of dysphagia (R28). These failures apply to 2 of 4 residents (R16, R28) reviewed for safety and supervision in the sample of 16.

Inspectors wroteBased on observation, interview, and record review the facility failed to label oxygen tubing. This applies to one of two residents (R31) reviewed for oxygen in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (R27) psychotropic medication was used to treat a medical condition for 1 of 5 resident's reviewed for psychotropic medications in the sample of 16.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to ensure a vaccine was refrigerated for 1 of 1 resident (R87) reviewed for medication storage in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's DNR (Do Not Resuscitate) choice was followed for 1 of 8 residents (R1) reviewed for improper nursing care in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was assessed after a fall, the assessment was documented, an incident report was filled out, and post-fall monitoring was completed for 1 of 8 residents (R8) reviewed for improper nursing care in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely position a resident (R1) in bed during care and safely transfer the resident after a fall. This failure resulted in the resident falling out of bed and sustaining multiple rib fractures. The facility also failed to identify a resident's (R2) transfer status in the plan of care, safely transfer the resident, and apply a wheelchair positioning device for the resident with a known behavior of unsafely leaning to the side. This applies to 2 of 4 (R1 and R2) residents reviewed for safety.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's (R1) physician and representative after the resident had a change in condition requiring to be transferred to the hospital after a fall. This applies to 1 of 3 (R1) residents reviewed for change in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its reporting abuse policy for a resident with an injury of unknown origin. This applies to 1 of 4 (R2) residents reviewed for injuries.

Inspectors wroteBased on observation interviews and record reviews, the facility failed to readmit a resident after hospitalization. This applies to 1 of 6 residents reviewed (R4) for involuntary discharge in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to protect R1, a resident with dementia from sexual activity from R2, another resident with dementia with known sexual behaviors and a history of wandering into other resident's rooms. This failure resulted in R1 experiencing sexual abuse at the facility when R2 went into R1's room at night and went into R1's bed and sexually assaulted her in her bed. R1 is unable to give consent to the sexual activity and a reasonable person would not want to be touched without consent. This applies to 1 of 3 residents (R1) reviewed for sexual assault in the sample of 3. This failure resulted in an immediate jeopardy.

Inspectors wroteBased on interview and record review, the facility failed to conduct a complete and thorough investigation of an allegation of sexual abuse. This has potential to affect all 11 female residents (R1, R3-R12) residents that reside in the Dementia unit.

Inspectors wroteBased on interview and record review the facility failed to have a Director of Nursing on a full-time basis. This has the potential to affect all 37 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to test residents and staff for COVID following a Certified Nursing Assistant (CNA) calling in sick with COVID symptoms, failed to complete a line list to track positive residents, failed to submit positive COVID cases to the county health department and failed to show documentation of testing of staff and residents during a COVID outbreak. The facility also failed to have a water treatment plan in place to prevent and/or detect water borne pathogens. This has the potential to affect all 37 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to have an Infection Preventionist on staff to manage the facility's Infection Prevention and Control Program. This has the potential to affect all 37 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to review, revise, and implement interventions to prevent a resident from having future falls for 1 of 12 residents (R10) reviewed for care plans in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a full bed bath was provided and failed to ensure incontinence care was provided in a timely manner for 2 of 12 residents (R286, R6) reviewed for ADLs (Activities of Daily Living) in the sample of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to identify, assess, and provide treatment for a resident's coccyx wound for 1 of 3 residents (R181) reviewed for pressure injury in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transfer two residents using a mechanical lift for 2 of 12 residents (R6, R181) reviewed for safety in the sample of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor refrigerator temperatures for refrigerators in resident rooms for 2 of 12 residents (R231 and R232) reviewed for food storage/sanitation in the sample of 12.