Aperion Care International

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 19, 2026

  Based on interviews and record reviews, the facility failed to ensure resident safety and supervision while transporting one resident (R1) in a wheelchair without leg rests resulting in the resident sustaining a fracture This failure affected one residents (R1) out of six residents reviewed for safety and supervision. The findings include: R1's Face sheet dated 2/17/2026 documents a diagnosis of but not limited to other specified disorders of muscle, right side sciatica, unilateral primary osteoarthritis-right knee, age-related osteoporosis without current pathological fracture, and limitations of activities due to disability. […]

• Actual harm, isolatedF600Feb 4, 2026

  Based on interview and record review, the facility failed to prevent and protect a resident (R1) from physical abuse for one resident from another resident (R2), with potential of aggressive behaviors including verbally threatening to hit others, for three residents reviewed for physical abuse. This failure resulted in R1 observed with redness to her cheek and saying she was hit and R1 experiencing emotional distress and feelings of being unsafe in the facility. Findings include: On 02/02/2026 at 12:54PM, R1 states she was lying in her bed at approximately 8:30PM on Friday 01/30/2026 when an unknown male (identified as R2) walked into her room. R1 states she told R2 that he had entered the wrong room. […]

• Actual harm, isolatedF689May 5, 2025

  Based on observation, interview and record review, the facility failed to implement fall prevention interventions for a resident at high risk for falls for one (R1) out of three residents reviewed for falls in a total sample of three. These failures resulted in R1 had an unwitnessed fall on 04/01/2025. R1 sustained a left femur fracture. Findings include: Facility's final reported incident (FRI) report dated 4/2/25, documents in part, resident (R1) is alert and oriented to name. R1 needs consistent verbal cueing and reminder. R1's gait is unsteady, requires staff's assistance for transfers and ambulation. On 04/01/2025 at approximately 5:00 AM, resident (R1) observed in the room near bathroom on buttocks next to wheelchair. […]

• Actual harm, isolatedF684Feb 26, 2025

  Based on observation interviews and record review, the facility failed to provide emergency care for one resident (R2) who had an unwitnessed fall and complained of leg pain. This failure resulted in R2 sustaining a hip fracture that was not detected until more than twelve hours later. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: Displaced intertrochanteric fracture of right femur, unspecified fall, unsteadiness on feet, limitation of activities due to disability, other abnormalities of gait and mobility. On 2/20/25 at 11:50 PM, R2 stated, I was walking around when I fell . I told my nurse that I had fallen and my leg was hurting. […]

• Actual harm, isolatedF689Apr 17, 2024

  Based on interview and record review the facility failed to develop and implement individualized fall prevention interventions for one of three residents (R1) reviewed for falls. R1 fell four times in 26 days, including two falls on the same day (4/1/2024). This failure resulted in R1 falling and sustaining fractures of the sacral spine and coccyx on 3/12/2024. Findings include: On 4/12/2024 at 1:39 PM R1 was observed sitting in wheelchair behind nurses station. R1 said I fell five times, they told me not to get up. […]