North Aurora Living & Rehab Ctr

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medications doses as ordered by the physician. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for pharmacy services in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to sanitize dishes during dishwashing procedure. This applies to all 99 residents that received meals prepared and served in the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement their water management program plan, failed to conduct risk assessment to identify high risk areas, failed to document description of the facility's water system, and failed to implement control measures to prevent Legionella and other opportunistic waterborne pathogens spread within the facility's water system. This applies to all 99 residents who reside at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health services to residents with SMI (severe mental illness). This applies to 4 of 4 residents (R4, R12, R85 and R97) reviewed for behavioral health services in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident bathroom had a clean and working toilet. This applies to 2 of 3 residents (R78 and R91) reviewed for environmental concerns in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to repair a gap between the outside wall and the air conditioner unit on the exterior wall in a residents room, that caused cold air from the outside to flow directly into the room and failed to implement a system to notify maintenance staff of needed repairs. This applies to 1 of 3 resident (R31) reviewed for environmental concern in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for an emergency involuntary transfer and did not allow the resident to return to the facility. This applies to 1 of 3 residents (R1) reviewed for involuntary discharge in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to prevent the physical abuse of residents per facility policy. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident (R1) with the use of a mechanical lift. This failure resulted in the resident falling and sustaining fractures to the right hip, left pelvis, pubic bone, and lumbar vertebra. This applies to 1 of 3 residents (R1) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to follow manufacturer's maintenance recommendations for the safe use of a mechanical lift-sling transferring device. This applies to 1 of 3 (R1) residents reviewed for transfer equipment.

Inspectors wroteBased on interview and record review the facility failed to schedule a follow up doctor appointment for 1 of 3 residents (R1) reviewed for quality of care in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate and complete medical record after discharge for 1 of 3 residents (R2) reviewed for medical records in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's rights to be free from sexual and physical abuse by another resident in accordance with facility policy. This applies to 2 of 5 residents (R2 and R5) reviewed for abuse in the sample of 8. This failure resulted in psychological harm to R2 and R5. Both R2 and R5 expressed being scared of their peer who was the perpetrator of the abuse.

Inspectors wroteBased on interview and record review the facility failed to report one incident of resident-to-resident physical abuse to local law enforcement in accordance with facility policy. This applies to 1 of 5 residents (R4) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to report two incidents of resident-to-resident physical abuse to the State Agency in accordance with facility policy. This applies to 2 of 5 (R4, and R5) residents reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to investigate two incidents of resident-to-resident physical abuse in accordance with facility policy. This applies to 3 of 5 residents (R3, R4, and R5) reviewed for abuse in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the administration guidelines while administering eye drops. The facility also failed to obtain an uncontaminated blood sample for blood glucose monitoring. This applies to 2 of 9 residents (R24 and R46) reviewed for medication pass observation. The Findings Include: 1 R46 is a [AGE] year-old female admitted on [DATE]. A record review on R46's physician order sheet (POS) document Refresh eye drops, one drops each eye three times a day. On 11/13/24 at 01:22 PM, R46 was observed in her room sitting on her chair, and V4 (Licensed Practical Nurse/LPN) administered eye drops to R46's right eye while sitting on the chair. V4 pulled R46's right corner of the right upper eyelid and administered eye drops (Refresh) to the right eyeball. The eye drops fell on the eyeball and dripped onto her cheeks. On 11/14/24 at 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to securely store medications by having them at the bedside and failed to discard expired medications from the medication cart. The facility also failed to label and date insulin vials after initial use. This applied to 3 of 3 residents (R1, R16, and R50) reviewed for medication storage and label/date in a sample of 19. The Findings Include: 1 R1 is a [AGE] year-old male admitted with an admitting diagnosis, including type 2 diabetes. On 11/13/24 at 11:04 AM, V6 (Licensed Practical Nurse/LPN) was unable to locate the insulin (Novolin R) vial to administer the scheduled 10 units of insulin to R1. V6 opened a new insulin vial to administer 10 units of insulin to R1's left shoulder and put the vial back into the medication cart without labeling the vial with an open date. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide influenza and pneumonia vaccines to residents residing in the facility. This applies to 3 of 5 residents (R1, R59, R70) reviewed for immunizations in a sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R1) with full code status (attempt CPR). The facility also failed to have a system in place to ensure that Advance Directives are completed timely and available to direct care staff. These failures resulted in R1 not receiving CPR and expiring at the facility. These failures have the potential to affect all residents residing in the facility. The [DATE], Facility Data Sheet showed 96 residents reside at the facility. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE], when R1 was found not breathing and no CPR was initiated. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE], at 9:50 AM.

Inspectors wroteBased on observation, interview and record review the administrator failed to have a system in place to ensure that Advance Directives are completed timely and available to direct care staff. The facility also failed to coordinate advanced directives with hospice and guardian. The administrator failed to remove an employee being investigated for neglect during an active investigation and to summarize the findings of an investigative report. These failures have the potential to affect all residents residing in the facility. The [DATE], Facility Data Sheet showed 96 residents reside at the facility.

Inspectors wroteBased on interview and record review the facility failed to keep a resident free from neglect when they failed to initiate cardiopulmonary resuscitation CPR). This applies to 1 of 3 residents (R1) reviewed for interventions at time of death in a sample of 100.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their abuse policy when they failed to remove a staff from resident contact during an active neglect investigation, submit a timely final investigative report to the state agency, and formulate a conclusion after completion of the investigation. This applies to 1 of 3 residents (R1) reviewed for neglectful care in a sample of 100.

Inspectors wroteBased on interview and record review the facility failed to coordinate advanced directives with hospice and a guardian in a timely manner. This applies to 1 of 2 residents (R1) reviewed for hospice care in a sample of 100.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff used the wheelchair's footrests during transportation. This failure resulted in R4 falling from the wheelchair to the floor sustaining a forehead laceration and transfer to the emergency department. This Applies to 1 of 3 residents (R4) reviewed for falls and accidents in a sample of 10. A care plan revised on 04/24/2024 showed that R4 has risk factors that require monitoring and intervention to reduce the potential for self-injury. The updated care plan on 06/19/2024 instructed staff to instruct and help R4 use footrests when he is in his wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve substitute menu items with similar nutritional content as the main entree. This applies to 5 of 5 residents (R1, R7, R8, R9, R10) reviewed for dining in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify residents in advance and the reason for room changes or room transfer. This applies to 2 of the 3 residents (R1, R2) reviewed for room transfer in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a history of falls was provided hourly rounding as ordered by the physician and failed to implement new, individualized fall risk interventions for residents who experienced falls, to prevent further falls. This failure resulted in R1 experiencing an unwitnessed fall at the facility and sustaining a subdural hematoma and R2 falling and sustaining a laceration requiring closure with sutures. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for resident injury in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the administrator and the state agency as shown on the facility's policy. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a resident's injury of unknown origin. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good personal hygiene for residents who need assistance. This applies to 3 of 3 residents (R1, R2 and R3) reviewed for activities of daily living in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to supervise a newly admitted male resident (R4) with known hyper-sexual behaviors resulting in R4 entering 5 female residents' rooms (R1, R2, R3, R5, R6), sexually abusing (R1), and getting into bed with R2 and touching her shoulder. This applies to 5 of 5 residents (R1, R2, R3, R5, R6) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a female resident was protected from a male resident with a known history of hyper-sexual behaviors resulting in the sexual abuse of 1 female resident (R1). This applies to 1 of 5 residents (R1) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights, failed to monitor and review for weight loss, and failed to make recommendations for nutritional support for 1 resident (R90) that resulted in a severe weight loss of 23.83% (percent) over 4 months and required an 8-day hospitalization for treatment of rhabdomyolysis and hypokalemia. The facility also failed to complete a quarterly dietary assessment for 1 resident (R33) with a history of significant weight loss. Four residents were reviewed for weight loss in the sample of 20. The Immediate Jeopardy began on 5/5/23 when R90's weight decreased by 11.4% in one month and the physician/nurse practitioner (NP) were not notified and V3 Dietitian, did not identify or address the significant weight loss until 5/22/23. V1, Administrator, was notified of the Immediate Jeopardy on 10/3/23 at 9:38 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an infection control program for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents and staff. This applies to all 95 residents residing in the facility.

Inspectors wroteBased on interview, and record review the facility failed to have an Infection Preventionist working at the facility and overseeing the infection control program This applies to all 95 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dishwashing machine was in working order and able to drain. This applies to all 95 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a stop/duration date for 5 of 5 residents (R5, R57, R39, R93, and R150) reviewed for pharmacy services in the sample of 20.

Inspectors wroteBased on observation and record review, the facility failed to provide 1 of 20 residents (R82) with a bedside table in the sample of 20 reviewed for a safe, clean, comfortable, home-like environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a shower for 1 of 20 residents (R90) reviewed for Activities of Daily Living (ADL) in the sample of 20.

Inspectors wroteBased on observation, interview and record the failed to identify an open wound to bilateral heels prior to developing to a stage 2 pressure injury to 1 of 1 residents (R93) reviewed for pressure injury in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not left unattended at the resident's bedside when administering medications for 1 of 5 residents (R87) reviewed for pharmacy services in the sample of 20.