Every nursing facility in the United States must undergo traditional recertification surveys performed by Centers for Medicare and Medicaid Services (CMS) and state agencies. When the agencies are alerted to consistently poor performance by nursing staff members and administrators, the agency utilizes progressive enforcement solutions for improving the quality of care provided to the residents. The nursing home has the opportunity to make quick improvements and develop new and effective policies and procedures to ensure they maintain the higher standard of care.
If the facility is unable to change their performance of substandard care to ensure the safety and well-being of the residents, CMS and the state of Illinois may choose to terminate their contract with the nursing home in providing care to Medicare and Medicaid patients.
Currently, Aperion Care Jacksonville is designated a Special Focus Facility (SFF) and must make specific improvements immediate and has time to make certain adjustments to the level of care they provide. However, it may take months or years to be removed from the list as they undergo extensive continuing surveys and investigations to identify violations and determine how the administration and managers have corrected serious problems.
This 113-certified bed, Medicaid/Medicare-participating facility, provides a variety of cares and services to the residents of Jacksonville and Morgan County, Illinois. The facility is located at:
1021 N. Church St.
Jacksonville, IL 62650
(217) 245-4174
In addition to providing skilled nursing care, the facility also offers long-term living options, short-term rehabilitation solutions, and psychiatric rehabilitation.
When the surveyors identify a violation has occurred that causes significant harm or has the potential for causing significant harm at a nursing home, the facility may receive a fine. On December 7, 2016, Aperion Care Jacksonville (SFF) received a penalty of $13,408 for a violation of federal and state nursing home regulations.
The state of Illinois and the federal government routinely update their star rating summary system as an effective tool to better understand the levels of care nursing homes provide their residents. Currently, Aperion Care Jacksonville (SFF) maintains an overall one out of five stars rating compared to all facilities throughout the United States. This much below average ranking includes one out of five stars for health inspections, three out of five stars for quality measures, and one out of five stars for staffing.
A few of the safety concerns and investigations of formal complaints filed against the facility include:
Failure to Maintain a Resident’s Privacy and Confidentiality
In a summary statement of deficiencies dated December 7, 2016, the State surveyor noted that the facility had failed “to ensure privacy during care for [two residents at the facility]. Upon observation at 12:30 PM on November 29, 2016, the resident “was in the first bedroom closet [closest] to the hall lying naked with the curtain to the room door pulled, but not the curtain between the beds.” The resident’s “roommate was in bed awaiting lunch at the time with [the naked resident] in full visual range.”
In a separate incident, another resident was pulled out of the shower room at 9:30 AM on November 20, 2016 “following a shower. [That resident’s] hair was wet and hanging. She had a …. blanket laid over the front of her which left her sides and back exposed, and she was taken across and down the hall to her room.” The administrator interviewed on December 1, 2016, stated that “staff should ensure the privacy of all residents including [these two residents, one of which] had a habit of disrobing and lying naked most of the time.” Because of that, “the facility has decided to move [the resident to] the bed farthest from the door to the hall where the curtain can be pulled to ensure his privacy.”
Failure to Provide Every Resident Safety Protection from Abuse, Physical Punishment and Being Separated from Others
In a summary statement of deficiencies dated December 7, 2016, investigators noted that the facility had failed “to prevent verbal and mental abuse from occurring for [a resident].” A Final Investigation Report documents, dated November 9, 2016, revealed that a Certified Nursing Assistant reported another CNA, “after overhearing him speaking in a harsh tone toward [a resident] while in his room.”
The resident’s medical records reveal that the resident “is non-verbal, but can answer yes and no questions.” On that day, the resident received a shower and “had … an episode upon returning to his room.” The Certified Nursing Assistant walked into the resident’s “room and observed [the resident] urinating, and started to raise his voice asking him why in the hell he is doing that and called him stupid and nasty, that it wasn’t funny.”
Failure to Develop Policies That Prevent Mistreatment, Neglect or Abuse
After a record review and interviews, the state investigator noted that the facility had failed to “operationalized their policy on Abuse Prevention for [a resident] who had been verbally abused” involving the incident noted above. The State surveyor noted that the facility’s Abuse Prevention Program Policy documents verbal abuse as “use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.”
Failure to Provide Care for Residents That Builds or Maintains Their Dignity and Respect of Individuality
After a record review, interviews and observations, the State surveyor noted that the facility failed “to provide care for maintaining dignity [for two residents].” Upon observation at 12:25 PM on November 29, 2016, a resident “was pacing in the dining room during the lunch meal [whose] t-shirt was on backward and [with] several days of facial hair growth.”
The State surveyor reviewed the resident’s most MDS (minimum data set) that documents that the resident “has severely impaired cognition, is incontinent of urine and has a urinary catheter.” At 12:39 PM on November 29, 2016, the resident “was wheeled out of the dining room with [their] urinary drainage bag uncovered.” The survey reminded the facility of their Dining Observation policy that reads in part “the purpose of the observation of the meal service is to determine whether this service takes into account: Requirement to provide meal service with dignity and respect.”
Failure to Assist Individuals Requiring Help
In a summary statement of deficiencies dated December 7, 2016, the state investigator noted the facility’s failure “to provide adequate incontinent care and assistance when eating and grooming for [three residents].” One incident involved a review of an October 19, 2016, Care Plan for a resident who “has frequent loose discolored bowel incontinence with a goal to keep clean/dried by checking every two hours and assist as needed and provide. {Provide] care after each incontinent episode in part.”
However, observation of the resident at 9:28 AM on November 30, 2016, revealed that the resident “was lying to her left side. The cloth incontinent pad under [the resident] was soaked with urine to the edges, and a pressure ulcer heel dressing was loose, saturated with urine and had bloody drainage on it.” The resident “had a loose bowel movement on her in her buttocks.
Incontinent care was provided by a Certified Nursing Assistant who cleaned [the resident] with dispenser soap from the bathroom with one washcloth and rinsed another cloth that she wiped [the resident’s] in her buttocks.”
However, the surveyor observed the Certified Nursing Assistant using an inappropriate method while completing perinatal care that did not follow the facility’s undated Policy titled: Incontinency Care that reads in part:
“It is the policy of the facility to check a resident periodically in accordance with the assessed incontinent episodes or every two hours and provide perineal and genital care after each episode. The purpose is [of this care is] to prevent excoriation and skin breakdown, discomfort and to maintain dignity.”
Failure to Provide Proper Treatment to Prevent the Development of a New Pressure Sore Allow an Existing Pressure Sore to Heel
In a summary statement of deficiencies dated December 7, 2016, the state investigator noted that the facility “failed to timely identify, assess, treat, provide timely repositioning and monitoring pressure ulcers for [five residents].” The failure in part resulted in one resident “developing a deep tissue injury and Stage III avoidable pressure ulcers.
In a separate summary statement of deficiencies dated July 18, 2017, the state investigator noted the facility’s failure “to provide pressure ulcer treatments as ordered by a physician” for a resident readmitted to the facility on June 5, 2017. In accordance with physician’s orders, the nursing staff … applied non-sting skin prep and peri-wound” before applying “triple antibiotic ointment, then calcium alginate then gauze dressing changes twice daily.”
In a third separate summary statement of deficiencies dated May 10, 2017, the investigator noted that the facility had failed “to provide dressing changes and treatments as ordered [by the physician] for a resident.”
Provide Every Resident Environment Free of Accident Hazards
After a review of records, interviewing and observations, the state investigator noted the facility’s failure “to provide safe transfer techniques using a partial weight mechanical lift for [two residents at the facility].” In part, the violation involved a resident who “requires extensive assist for two staff members for transfers and has balance deficits.”
The surveyor observed the resident on the morning of November 30, 2016, when two Certified Nursing Assistants positioned the resident “in the doorway of the bathroom in his room and pulled the partial weight mechanical lift in front of him.” The resident’s “wheelchair was not locked and [one CNA assisted the resident] in placing his feet on the platform of the lift [whose] hands are spastic, and grabbing the arms of lift was difficult with his hands slipping off the arms of the lift at times.”
Both Certified Nursing Assistant cued the resident “to keep grabbing the lift and to stand up [who was] lifting up from his wheelchair and moving toward the toilet. As he moved, the sling started to slide up, and he let go of the stand [and] moved toward the toilet, his arms were straight up with the sling sliding up under/over his armpits. Both staff [members] were on the other side of the lift and not within reach of [the resident] as he was lowered to the toilet.” The surveyor noted that the facility failed to follow their policy titled Technical Resource – How to Use a Lift.
Failure to Inform the Resident, the Resident’s Doctor and a Family Member of a Change in Situations of the Resident Including a Decline in Health or an Injury
In a summary statement of deficiencies dated February 1, 2017, the state investigator noted the facility’s failure to “notify the physician of the resident’s refusal to take anti-psychotic medication and [a failure to] notify the psychiatrist when a resident [disregarded the] facility’s Against Medical Device (AMA).”
The state investigator noted that the nursing staff failed to follow their undated facility policy titled Medication and Treatment Refusal.” The policy guides staff members to document incidents related to the resident’s refusal of medication or treatment “that must be recorded in the resident’s medical record [ along with] the date and time that the physician was notified, as well as the physician’s response.”
Failure to Develop, Implement and Enforce Policies of for Bid Mistreatment, Neglect or Abuse of Residents
After conducting interviews and record reviews, the State surveyor noted that the facility “neglected to follow operational policies related to discharging a resident against medical advice and the emergency medical care of the mentally ill adjudicated resident, as established by the State Guardianship & Advocacy Commission.”
These failures resulted in staff allowing [the resident] to leave the facility Against Medical Advice on December 16, 2016. As a result of this, [the resident’s] whereabouts are currently unknown. These failures resulted in an Immediate Jeopardy and have the potential to affect the other nine adjudicated residents currently residing in the facility.”
If you were injured at Aperion Care Jacksonville (SFF) or any other nursing facility, hiring an Illinois nursing home attorney who specializes in neglect and abuse cases could be financially beneficial.
Working on your behalf, the lawyer can seek out financial remedies to ensure your family receives the monetary recovery they deserve.
Also, the actions of your attorney can help you obtain justice for those who caused you harm to ensure no others are injured or killed because of negligence, abuse or mistreatment.
For more information on the laws and regulations applicable to Illinois nursing homes, look here.
If you are looking for a local attorney or for information on a nursing facility in a particular city, please visit the pages below:
Attorney Jonathan Rosenfeld
Licensed in Illinois
Jacksonville Nursing Home Injury Attorney Nursing Home Law Center LLC Home