Both the State of Illinois and Centers for Medicare and Medicaid Services (CMS) conduct routine surveys, inspections, and investigations at nursing home statewide. Their efforts can help identify serious concerns, violations and deficiencies occurring in Illinois convalescent homes and rehabilitation centers. Once problems are identified, the regulators cite the nursing home to ensure appropriate measurements are taken to improve the level of care they provide the residents or changes are made to facility policies and procedures.
In egregious cases, regulators will designate the facility as a Special Focus Facility (SFF) and add the Center to the Medicare deficiency watch list. Additionally, the facility must undergo additional unscheduled surveys and unannounced inspections to investigate formally filed complaints.
In 2017, regulators designated Aperion Care Bloomington as a Special Focus Facility and add the Home to the watch list. Likely, the facility route will remain under the watchful eye of federal and state regulators in the years ahead. Some serious concerns, deficiencies, and violations involving this facility are listed in detail below.
This long-term care Center is a “for-profit” 115-certified bed of Home providing cares to residents of Bloomington and McLean County, Illinois. The Facility is located at:
1509 N. Calhoun St.
Bloomington, IL 61701
(309) 827-6046
In addition to providing skilled nursing care, the facility also offers long-term living solutions, short-term rehabilitation care, and psychiatric rehabilitation.
Federal and Illinois regulators routinely update their convalescent home database systems containing a complete list of all opened investigations, safety concerns, incident inquiries, dangerous hazards, filed complaints, and health violations. This information is available on numerous websites including Medicare.gov.
Currently, Aperion Care Bloomington maintains an overall one out of five stars compared to all nursing homes in the US. This ranking includes one out of five stars for health inspections, one out of five stars for staffing issues, and two out of five stars for quality measures. Medicare also refused a request for payment on March 31, 2015, due to substandard care.
Over the last thirty-six months, nursing home regulators have investigated 54 formally filed complaints and seven facility-reported issues that all resulted in citations. Some serious concerns, deficiencies, and violations involving this facility include:
In a summary statement of deficiencies dated January 18, 2017, the state investigator noted the facility’s failure to “notify the physician that medication was not administered as ordered [for two residents] reviewed for medication availability.…” This incident involved a review of a resident’s Progress Notes dated from January 12, 2017, through January 17, 2017, which “do not include documentation of [the resident’s] physician being notified of [the resident’s] prescribed medication being unavailable and not administered.”
The state investigator interviewed the Director of Nursing on the morning of January 18, 2017, who stated that the resident’s “missing the medication Pyridostigmine resulted in a make medication error.” The Director stated that “I cannot see any documentation of the resident’s physician being notified [and that the] facility staff should have notified him.”
In a separate summary statement of deficiencies dated May 2, 2017, the surveyor documented the facility’s failure “to notify the physician of missed medications for [one resident].” The surveyor noted that a resident’s Summary Report dated May 2, 2017, and the resident’s Medication Administration Record revealed that the resident had missed doses of their prescribed medication on certain days.
However, the surveyor documented that there “was no documentation that the resident’s physician was notified of the resident’s refusal” to take the medication on different dates at different times. The facility’s Administrator stated that the Physician “should have been notified each time of the resident’s refusal [to take the medication].” This deficiency was supported by the facility’s January 1, 2014, Change in Condition Physician Notification Overview Guidelines that reveals that “medical care problems are to be communicated to the attending physician in a timely, concise and thorough manner.”
In a summary statement of deficiencies dated January 18, 2017, the state surveyor documented a “failure to notify the physician and power of attorney of an allegation of physical abuse for [one resident].” This incident involved reviewing the facility’s undated Final Abuse Investigation Report documents on January 13, 2017, at approximately 4:50 PM.” The report revealed that the resident “was using the microwave and the dietary alcove. Another resident walked up behind [the first resident] to get some paper towels and elbowed [the resident] in the back. This report documents that the resident was sruck in the back by the other resident is “mentally impaired.”
The surveyor reviewed the mentally impaired resident’s Medical Records dated January 13, 2017, through January 18, 2017. The records did not “document that the physician or power of attorney was notified of an allegation of physical abuse.” During an interview with the facility’s Director of Nursing, it was stated that “the physician and power of attorney were not notified of the allegation of physical abuse [and that] the facility nurses should have notified the physician and power of attorney…”
In a summary statement of deficiencies dated March 29, 2017, the state investigator documented the facility’s failure “to operationalize their abuse prevention program and investigation of injuries of unknown origin policy by failing to report and investigate an injury of unknown origin for [one resident].”
The incident involved a documented cognitively impaired resident who “was ambulating back in the bathroom” at 10:15 AM on March 20, 2017, with a “bandage on [their] left forearm and above [their] left side.” The resident was “unable to state what happened.” The surveyor reviewed the resident’s Injury Report dated March 24, 2017, documented by a Licensed Practical Nurse. The report “is blank[with] no information documented. There are no documented eyebrow or forearm injuries in [the resident’s] medical records.”
The state investigator interviewed the facility’s Administrator on the afternoon of March 20, 2017. The Administrator was questioned about the resident’s injuries and stated, “I do not know if the resident had a fall or not on March 24, 2017, you would need to ask” the Licensed Practical Nurse (LPN).
The LPN stated in an interview the following day that “on March 24, 2017, around 4:00 PM, a CNA (Certified Nursing Assistant) had asked [the LPN if the resident] had fallen due to [the resident] having the skin tear on the arm.” The LPN stated that they “had not been told anything about a fall or injuries regarding [the resident] from the prior shift, so the LPN assessed [the resident].”
During an interview with the Director of Nursing, it was noted that the Quality Assurance Nurse “is the on-call person [and that the Administrator] would know about the injuries because [the Administrator] reads and signs off on the report (which has not been completed yet).” The Administrator stated that if the resident apposite as “injuries were of an unknown origin, they should have been immediately reported to me because I would have opened an investigation on it and reported it.”
In a summary statement of deficiencies dated March 29, 2017, the state investigator documented that the facility had failed to “follow implemented post-fall interventions and implement new post-fall interventions for [one resident] reviewed for falls.” The incident involved a resident who requires the extensive assistance of one staff for transfer and ambulation. The investigator reviewed the resident’s six Fall Risk Assessments dated December 27, 2016, through March 19, 2017. Every document lists that the resident is “at risk for falls.”
Additionally, the resident’s Care Plan dated December 9, 2016, reveals that the resident is “high risk for falls related to confusion, gait/balance problems, unaware of safety needs, wandering.” The document also states that certain intervention should be followed including the Fall Policy, nursing to order non-schizophrenics, audible electronic alarm in place when up in a chair, ensure it is on and working and ensure bed alarm is in place and working.”
The surveyor reviewed the resident’s initial fall occurrence form dated March 19, 2017, at 11:25 PM. The report documented by a Licensed Practical Nurse revealed that the resident “was on the floor in their room lying flat on [their] back with blood noted to bilateral arms and a laceration to the back of the head.” However, the “Occurrence Report does not document that [the resident’s] bed alarm was sounding or not.”
Documentation by the Licensed Practical Nurse revealed that the resident “had a bed alarm on the bed, but it was not alarming due to [an electrical shortage] in it, so it was replaced.” The LPN stated that the Certified Nursing Assistants who provide the resident’s care “should check the alarm to the beginning of the shift to ensure they are working properly, but they had not been to [the resident’s] room yet.
In a separate summary statement of deficiencies dated July 19, 2017, the state investigator documented the facility’s failure “to safely transfer” a heavy resident who weighs more than 350 pounds who is documented as “at risk for falls.” The incident involved a resident whose Care Plan involved interventions including to ensure that the resident’s “feet are properly placed on the floor of the standing lift and both feet flat on the platform.” Documentation also reveals that while transferring, the resident’s “knees are to be up against the leg rest before lifting to a standing position and [the resident] is …dependent on to staff or transferring.”
Evidence shows that on the late morning of July 13, 2017, two Certified Nursing Aides transfer the resident “from the wheelchair to the toilet.” Both Certified Nursing Aides “place a sling around the resident’s waist, hooked it to the lift and positioned the resident’s feet on the platform of the lift.” However, the resident’s “left knee was not positioned up against the rest. While being lifted to a standing position and during the transport to the toilet, [one CNA] held the resident’s left foot to keep it from sliding off the platform of the lift.”
During this time the resident “was holding onto the frame of the lift with her right arm, but her left arm was hanging flaccid at her side.” Both CNAs “stated they are unable to get the resident’s left knee (shin) position against than the rest of the standing lift because [the resident’s] left leg is bowed.” The aides also stated that the resident’s “left arm always hangs to the side during transfers using the standing lift [that is an] old standing lift.”
The Director of Nursing examined the Standing Lift and read the manufacturer’s labeled to determine that the “weight capacity of the lift is 350 pounds”, which is less than the resident’s weight. The Director stated that the lift should not be used because it was not safe due to the resident’s weight being “over the weight capacity of the lift.”
In a summary statement of deficiencies dated March 29, 2017, the state investigator documented that the facility “failed to have the services of a Registered Nurse for eight consecutive hours every day” as required by law. This deficiency by the nursing staff and Administrator “had the potential to affect all 83 residents in the facility.”
A review of the Facility Data Sheet “does not identify a Director of Nursing. The staff and spreadsheets by the facility dated March 2, 2017, to March 15, 2017, and March 16, 2017, March 27, 2017, list no hours for the Director of Nursing after March 10, 2017.” The Human Resources Director “reported the facility presently has no Director of Nursing.”
In a summary statement of deficiencies dated May 2, 2017, the state investigator documented the facility’s failure “to disinfect the blood glucose testing machine after use.” This deficient practice by the nursing staff “has the potential to affect [five residents] reviewed for blood glucose testing machine use.”
Surveyors observed a Licensed Practical Nurse (LPN) on the morning of May 1, 2017, performing “a blood sugar check for [a resident] with a blood glucose testing machine.” The LPN wiped the blood glucose machine with the disinfected wipe for ten seconds and placed the machine on a paper towel on top of the medication cart.” The LPN “then, the blood glucose machine with another paper towel. At 10:39 AM, the blood glucose machine was dry, two minutes after wiping the machine.”
The surveyor reminded the facility of their undated Maintaining the Blood Glucose Meters the documents that the purpose of the policy “is to prevent the spread of microorganisms. Other parts of the policy read in part:
“This policy also documents the blood glucose monitor should be cleaned and disinfected between each resident test. This policy also documents to wipe the meter with a wipe and allow to air dry for one minute at room temperature.”The surveyor noted that “manufacturer’s directions for the use of the disinfected whites dated May 2, 2017, documents the services to remain wet for three minutes to kill Clostridium difficile (C-diff) spores. [C-diff are highly contagious life-threatening bacteria].
If you suspect your loved one was the victim of abuse or neglect while residing at Aperion Care Bloomington, or any nursing home, contact a lawyer today. With legal representation, your attorney can ensure that you file all the necessary documentation in the appropriate Illinois county courthouse. The law firm working on your behalf will build a case and negotiate a settlement or take your claim to trial.
Your family will pay no upfront fees. This is because personal injury attorneys that handle nursing home abuse and neglect cases accept claims for compensation through contingency agreements. This arrangement allows immediate legal representation while postponing payment for legal services until after the case has been resolved successfully and you receive monetary compensation.
Sources:
Attorney Jonathan Rosenfeld
Licensed in Illinois
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home