Federal inspectors cited the facility for immediate jeopardy violations during a June 2024 complaint investigation that revealed dangerous understaffing patterns affecting 147 residents on two floors.
One resident described the consequences in stark terms. "I need to be changed as soon as possible," the cognitively intact patient told inspectors at 7:15 a.m. "The night shift only had one CNA and I was not changed at all after I was placed in bed at 8:00 p.m. I have urine and poop in the brief. I cannot wait any longer, I do not like to feel dirty and with bad odor."
When nursing assistants finally provided care 15 minutes later, they removed an undergarment "visibly soiled with yellow and dark brown substance." The aide performing the care explained what had happened: "This happens when the prior shift does not have enough people. It will affect the incoming shift; today is going to be a very busy day."
The nursing assistant who worked alone that night confirmed the impossible situation. "I worked by myself last night, it is very hard because I was not able to provide the care the patients needed," she told inspectors. "One CNA is on the floor for more than 75 patients. I can only do what I can do. I know some residents were not attended to last night."
Another resident, also cognitively intact, described the pattern of neglect. "Last night it was very bad, we had only one CNA and I needed to wait a very long time because it was only one CNA working on the floor. I am very upset because I needed help and they did not come to help me. The issue of not having enough staff happens very frequently."
The staffing crisis extended beyond overnight shifts. During the day shift, inspectors found four nursing assistants caring for 74 residents on the fourth floor dementia unit, when staff said five to six were normally required. Each aide was responsible for 18 residents.
"We are each supposed to give three showers usually but when there's only four of us working it's not possible," one nursing assistant explained. She described the impossible logistics: residents eating in the dining room had no supervision from nursing staff while aides delivered meal trays to other residents and helped feed those who needed assistance.
Two nursing assistants were working double shifts that day, having already completed the 7 a.m. to 3 p.m. shift before starting the 3 p.m. to 11 p.m. shift.
The registered nurse working the fourth floor dementia unit summarized the crisis: "Working with one CNA is not acceptable. It is not enough help, we need at least three CNAs to provide the care the residents need."
Facility managers claimed ignorance of the staffing shortages despite their severity. The assistant director of nursing told inspectors: "I was not aware that we only have one CNA working on 11 p.m. to 7 a.m. shift on the 4th floor; having only one CNA is not enough on the floor. Having two CNAs on the 3rd floor is not enough help as they cannot provide the appropriate services."
The director of nursing expressed similar surprise: "I was not aware that we only have one CNA on the fourth floor and two CNAs on the third floor, having one CNA to 75 patients is not ideal. It is not what we want as they cannot provide the care that residents need; that is common sense."
The assistant administrator, covering for a vacationing staffing coordinator, acknowledged the problem: "One CNA on the fourth floor is not enough help to care for the residents, we usually have at least three CNAs."
When inspectors examined the facility's assessment documents, they discovered a fundamental failure in planning. The administrator admitted the facility had "no staffing policy." The facility assessment dated January 16, 2024, listed the overall staffing number as "00" and described activities of daily living staffing as simply "sufficient" without any numerical analysis.
The document included a note requesting specific staffing calculations: "Please document total number/average/range of staff required to ensure sufficient number of qualified staff are available to meet each resident's needs." That analysis was never completed.
The administrator could not explain how the facility assessment was used to determine staffing needs, telling inspectors only that "it is the facility assessment they get from corporate and that is what they use."
The immediate jeopardy designation triggered an extensive corrective action plan. The facility committed to reassessing all residents with substance abuse histories, updating policies for overdose response, and retraining all nursing staff on emergency protocols including naloxone administration and CPR.
Quality assurance meetings will now review nursing competencies monthly, and the facility pledged to monitor the next five uses of naloxone to ensure proper protocol adherence. Random competency testing of three nurses per week will continue for 12 weeks.
The 209-bed facility must also revise its facility assessment to include actual staffing numbers rather than vague sufficiency ratings. The assistant director of nursing and director of nursing will oversee ongoing monitoring of staffing levels and competency verification.
The understaffing crisis at Aperion Care Forest Park illustrates a broader problem in nursing home care. Federal research shows facilities providing less than 4.1 hours of daily nursing care per resident face increased risks of bedsores, weight loss, and other harm. With one aide caring for 76 residents overnight, the facility provided approximately 0.1 hours of nursing assistant time per resident during that shift.
The residents who spent that night waiting for care, sitting in soiled briefs for 11 hours, experienced the human cost of inadequate staffing in the most basic and dignifying terms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Forest Park from 2024-06-23 including all violations, facility responses, and corrective action plans.
