Aperion Care Lakeshore

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 1, 2026

  Based on interview and record review, the facility failed to provide supervision to prevent elopement for one [R1] out of four [R1, R4, R5, R6] residents reviewed for elopement. This failure resulted in R1 eloping through the front entrance three times including on 10/12/26 sustaining open areas to both feet, and on 2/6/26 sustaining a fall with a close head injury and left lower lip laceration requiring sutures. Findings Include:This was identified as an Immediate Jeopardy which began on 10/12/25.On 2/27/26 at 1:52 pm, the administrator was notified of the Immediate Jeopardy. On 02/28/26 at 3:54PM, the facility abatement plan was approved.The Immediate Jeopardy was removed on 3/1/26. […]

• Immediate jeopardy, isolatedF689Jun 8, 2021

  Based on interview and record review, the facility failed to supervise, monitor, and prevent three residents (R1, R9, and R10) with known substance abuse diagnoses from trafficking illicit drugs and alcohol in the facility. This resulted in R1's death due to substance abuse. The Immediate Jeopardy began on [DATE] when R1 expired. V24 (Administrator), V1 (Assistant administrator) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE]. The immediacy was removed on [DATE], however remains out of compliance at severity level two. […]

• Actual harm, isolatedF600Sep 19, 2025

  Based on interview and record review, the facility failed to prevent and protect residents from physical abuse. This failure affected one (R3) out of three residents reviewed for abuse. This failure resulted in R2 sustaining a closed fracture of orbital wall.Findings include:R3's admission record shows admission date on 12/31/24, with diagnoses not limited to Chronic Kidney Disease, Hypo-Osmolality and Hyponatremia, Hypokalemia, Osteoarthritis, Hypertension, Other Abnormalities of Gait and Mobility, Fracture of Other Specified Skull and Facial Bones, Left Side, Initial Encounter for Closed Fracture (added 09/14/25). R3's MDS (Minimum Data Set), dated 06/26/25, reveals R3 is cognitively intact and requires supervision or touching assistance for mobility. […]

• Actual harm, isolatedF600Sep 10, 2025

  Based on record review and interview, the facility failed to follow their abuse policy for two residents (R1, R2,) out of five residents reviewed abuse. This failure resulted in staff not intervening in a timely manner, thus allowing R2 to hit R1 in the face, causing an injury to R1's right eye and nose.Findings include:R1's 8/26/2025 22:54 Nurses Note Narrative states: An agitated resident went into resident room and made contact with her. Resident was immediately separated from her and secure her safety. Complete assessment performed, provided first aid interventions and called 911. NP (Nurse Practitioner) notified. Family notified. Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) notified. Offered pain medication. […]

• Actual harm, isolatedF686Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers; failed to ensure a resident's wound dressing is intact as ordered by the physician; and failed to complete skin assessments accurately. This failure caused 1 resident (R2) to develop a 25x10 cm unstageable pressure ulcer to the sacrum and sustain severe pain (7/10). This failure affects 1 resident (R2) in a sample of 4 residents reviewed for pressure ulcers. Findings Include: R2's Face sheet, dated 4/21/2025, documents a diagnosis of but is not limited to Failure to thrive, Dysphagia, Major Depressive Disorder. Review of R2's Weekly Skin Assessments documents, on 3/12/2025 R2's skin was intact with no concerns. […]