Aperion Care Arbors Michigan City

In the surveyor’s words

From the most serious findings on record at Aperion Care Arbors Michigan City, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 1, 2026

  Based on record review and interview, the facility failed to initiate effective resident-specific interventions and provide adequate supervision to prevent the elopement from the facility of a resident with a diagnosis of dementia, a history of exit-seeking behaviors and a wanderguard (door alarm bracelet) in place for 1 of 3 residents reviewed for elopement risk. The resident exited the building without the knowledge of the staff working in the facility and was found the next day by the local police department and was taken to the hospital Emergency Room. (Resident B)The Immediate Jeopardy began on [DATE], when the facility was unaware that the resident had exited the facility without supervision. […]

• Immediate jeopardy, isolatedF600Dec 1, 2022

  Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse by a staff member which resulted in a cognitively impaired resident sustaining a fractured skull and head laceration requiring staples for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 9/11/22 when the physical abuse of a QMA punching a resident occurred to Resident B. The Executive Director was notified of the immediate jeopardy at 1:37 p.m., on 11/30/22. The immediate jeopardy was removed and the deficient practice was corrected by 9/13/22, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The record for Resident B was reviewed on 11/29/22 at 1:20 p.m. […]

• Actual harm, isolatedF686Dec 13, 2024

  Based on observation, record review, and interview, the facility failed to ensure interventions to provide effective pressure relief to the coccyx were implemented for a resident readmitted with a stage two (a partial thickness loss of skin) pressure injury on the coccyx and failed to ensure the physician was notified when the wound deteriorated. (Resident F) This deficient practice resulted in the wound deteriorating to a stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that required two surgical debridements. […]

• Actual harm, isolatedF580Feb 15, 2023

  Based on record review and interview, the facility failed to promptly notify the Physician of abnormal laboratory findings, resulting in a delay in treatment for which the resident was hospitalized for septic shock and required intubation and ultimately death for 1 of 4 residents reviewed for a change in condition. (Resident E) Finding includes: The closed record for Resident E was reviewed on [DATE] at 4:35 p.m. Diagnoses included but were not limited to, COPD, respiratory failure, acute kidney failure, peg tube, epilepsy, anxiety, and heart failure. There was Minimum Data Set (MDS) assessment available for review. […]

• Actual harm, isolatedF600Feb 15, 2023

  Based on record review and interview the facility failed to protect a resident's right to be free from neglect related to the failure of monitoring/assessing a dialysis perma catheter, lack of Physician notification of abnormal lab results and failure to administer oxygen for a resident in respiratory distress which resulted in a hospitalization for septic shock and required intubation and ultimately death for 1 of 3 residents reviewed for neglect (Resident E) Finding includes: The closed record for Resident E was reviewed on [DATE] at 4:35 p.m. […]