Aperion Care Elgin

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 22, 2024

  Based on interview and record review, the facility failed to ensure a resident with substance use disorder was safe for independent community access after being hit by a car the previous day while out in the community. This failure resulted in R2 being found on the side of the road by a bystander and requiring hospitalization . Hospital records show R2 had fractures of the left fourth through 12th ribs, and an elevated blood alcohol level. This applies to 1 of 3 residents (R2) reviewed for accidents in the sample of 6. […]

• Actual harm, isolatedF695Feb 15, 2025

  Based on observation, interview, and record review the facility failed to ensure emergency sized tracheostomy tubes for a resident (R1) who required tracheostomy care were available. This failure resulted in R1 experiencing acute respiratory distress and requiring an emergency hospitalization for acute respiratory failure. R1 had to be connected to mechanical ventilation for emergency respiratory support. The facility also failed to ensure licensed nurses were trained on how to change tracheostomy tubes and to dispose of expired tracheostomy inner cannulas. […]

• Actual harm, isolatedF689Feb 11, 2023

  Based on interview and record review, the facility failed to ensure a resident was safely transferred by using a mechanical lift and two staff assistance to prevent injuries. As a result, R1 sustained an acute distal femur fracture and was admitted to the hospital. This applies to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7 Findings include: On 02/10/2023 at 10:30 AM and 3:30 PM, V2 (Director of Nursing/DON) said R1 uses a mechanical lift with two staff assistance and on 02/08/2023 around 9:00 AM V6 (Certified Nursing Assistant/CNA/Hospice) transferred R1 from wheelchair to shower chair without using a mechanical lift and asking for help. […]

• Actual harm, isolatedF692Aug 31, 2022

  Based on observation, interview, and record review, the facility failed to assess and implement interventions to prevent significant weight loss of a resident. This failure resulted in R54 sustaining a significant weight loss of 23 pounds (14.94 percent) over 6 weeks. This applies to 1 of 2 (R54) residents reviewed for weight loss in a total sample of 19 residents. The findings include: R54's EMR (Electronic Medical Record) showed R54 was admitted to the facility from a acute care hospital on July 7, 2022 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R54's MDS (Minimum Data Set) dated July 14, 2022, showed R54's cognition was severely impaired and required limited assistance of facility staff for eating. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2025

  Based on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen and during meal service in the dining room. This applies to all 84 residents that received foods prepared in the facility kitchen. The findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated April 21, 2025 showed that the facility census was 86 residents. Facility provided information that two residents are NPO (nothing by mouth) status. On April 21, 2025 at 09:19 AM, the initial tour of facility kitchen was done in presence of V3 (Dietary Manager). V5 (Dietary Aide) was washing dishes at a low temperature dish machine. […]