Aperion Care Dolton

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 30, 2024

  Based on interview and record review, the facility failed to adequately supervise a resident who is at risk for aspiration and requires staff assistance during meals (R3) and failed to provide adequate staff supervision for a resident during smoking (R4). These failures affected two (R3, R4) of four resident reviewed for accidents and supervision and resulted in R3 sustaining an injury during mealtime, while in her room unsupervised and required treatment of two sutures; R4 was found on the floor while out on the patio, unsupervised, during a smoke break and required transfer to local hospital for evaluation of swelling to forehead. […]

• Actual harm, isolatedF690Jan 25, 2024

  Based on observation, interview and record review, the facility failed to provide appropriate treatment and services for care of a resident with a clinically justified indwelling catheter that affected 1(R1) of 3 residents in the sample of 3 reviewed for catheter care. This failure resulted in R1's emergent transfer to an acute care hospital where resident was diagnosed and treated in the ICU for septic shock and injury to the urethra. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to Quadriplegia; Neuralgia and Neuritis; Neuromuscular Dysfunction of Bladder; Major Depressive Disorder; and Hypertension. […]

• Actual harm, isolatedF689Dec 12, 2023

  Based on interview and record review, the facility failed to place effective fall prevention interventions to include monitoring to reduce or prevent the risk of falling for a cognitively impaired resident with a behavior of getting out of bed unassisted. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident suffering resulting in a hematoma to the left eye. Findings Include: R1 is an [AGE] year-old with the following diagnosis: Alzheimer's Disease, Dementia, and Adult Failure to Thrive. A Fall note dated 12/5/23 documents around 4:35 AM R1 was found in R1's room on the floor. The physician was notified and ordered to send R1 out to the hospital for an evaluation. The ambulance arrived around 7:15 AM. […]

• Actual harm, isolatedF686Aug 17, 2023

  Based on interview and record review, the facility failed to follow their policy addressing pressure injury and skin assessment. This failure affects one (R1) out of three residents reviewed for pressure injuries and resulted in a delay in treatment and assessment for R1 who developed a Stage III pressure ulcer to the sacrum and deep tissue pressure injury to the left heel. Findings include: R1 is a [AGE] year-old female admitted to the facility 8/30/2016 for long term care. According to nursing progress notes the evening of 6/5/23, R1 was sent to the emergency room for evaluation after a fall and returned to the facility several hours later the following morning. Upon return, facility staff did not indicate any pressure injuries were present. […]

• Actual harm, isolatedF688Dec 23, 2022

  Based on observations and interviews, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions for one resident (R64) with a decline in range of motion bilateral hands out of three reviewed for a decline in functional abilities in a sample of 20. R64 has developed a contracture of bilateral hands, left worse than right, and is unable to extend fingers fully. Findings include: On 12/20/22 at 10:00am, R64 was observed lying in bed with both hands closed. On 12/21/22 at 8:40am, this surveyor observed V2 DON (director of nursing) extend R64's fingers on both hands. V2 stated that V2 is unable to fully extend the fingers on either hand. […]