Aperion Care Forest Park

In the surveyor’s words

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

• Immediate jeopardy, patternF689Oct 27, 2023

  Based on interview and record review the facility failed to prevent the overdose of illicit drugs at the facility for 5 of 12 residents (R1, R2, R3, R12, and R9) reviewed for substance abuse on the sample list of 13. This failure resulted in an immediate jeopardy. The immediate jeopardy began on [DATE] at 11:23 PM when R1 and R2 who were roommates, were both found unresponsive. R2 required CPR, Narcan, and emergency services. R1 required Narcan and emergency services. On [DATE] at 1:15 PM, R3 was found unresponsive and required Narcan and emergency services. On [DATE] at 4:02 PM, R12 required Cardiopulmonary Resuscitation (CPR), Narcan, and emergency services and again on [DATE] at 1:30 PM, R12 required Narcan and emergency services. […]

• Immediate jeopardy, patternF886May 4, 2023

  Based on interview and record review the facility failed to implement their Coronavirus (Covid-19) testing policy to prevent or reduce the spread of Covid-19 on the third floor nursing unit. This failure affected 25 of 45 (R16, R18 - R36, and R38- R43) residents reviewed for outbreak testing, and prevention of the spread of Covid-19. This failure resulted in V55 (nursing aide) testing positive on 3.29.23 the facility failed to follow their policy and test the residents who received direct care from V55 (R16, R19 - R36). The failure resulted in R19- R21 testing positive 13 days later. R18 displaying signs and symptoms of Covid-19 on 4.6.23, the facility failed to immediately isolate and test R18 allowing R18 to go out to the dentist. […]

• Immediate jeopardy, isolatedF684Mar 18, 2025

  Based on observations, interviews, and record reviews, the facility failed to follow its physician orders policy and hypoglycemia guidelines and administer emergency medication to treat a resident exhibiting signs and symptoms of severe hypoglycemia (low blood sugar level) for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently. The immediate jeopardy began on 2/21/25 when R1 was found unresponsive and with a blood glucose level of 29. V1 and V2 were notified of the immediate jeopardy on 03/13/2025 at 9:35 AM. […]

• Immediate jeopardy, isolatedF760Mar 18, 2025

  Based on interviews and record reviews, the facility failed to follow professional standards of nursing care and clarify with the physician the frequency and route of administration of insulin 70/30 prior to administering the medication. This failure affected one resident (R1) out of three reviewed for significant medication errors in a sample of 4. Prior to admission, 20 units of insulin 70/30 was administer to R1 subcutaneously once a day. The order was changed on 2/19/25 at 00:50 AM to insulin 70/30, administer 20 units intramuscularly three times a day. […]

• Immediate jeopardy, isolatedF689Jun 23, 2024

  Based on interview and record review, the facility failed to have a written policy to address the response to an opioid overdose and failed to ensure that staff were trained and competent in monitoring of a resident after administration of Narcan medication. The facility also failed to follow recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration) for the administration and monitoring of a resident assessed to be at risk for substance abuse and who received Narcan medication for a suspected overdose. This failure affects one of one (R11) resident reviewed for overdose treatment. These failures resulted in R11 not being monitored in accordance with SAMHSA recommendations after receiving Narcan while in the facility for a suspected overdose. […]