Aperion Care Westchester

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 25, 2024

  Based on interview and record review the facility failed to develop an effective plan to prevent and/or reduce the risk of falling for a resident identified to at high risk for falls, and failed to follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This affected 6 of 6 residents (R1, R2, R4, R5, R6 and R7) reviewed for falls and fall risk assessments. This failure resulted in R1 having multiple falls R1 had a fall in his room on 8/27/24 at 7:45AM, and then another fall same day at 1:47PM in the dining room that resulted laceration in left side eye brow forehead requiring sutures on 8/27/24 and third fall on 9/12/24 in the dining room that resulted in left eyebrow laceration re-opening. […]

• Actual harm, isolatedF686Jun 28, 2024

  Based on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound. The findings include: 1. R1's Wound Assessment Report dated 2/4/24 shows that she admitted to the facility with an unstageable pressure ulcer on her right heel measuring 5.5 cm (centimeters) x 6.8 cm x 0.1 cm with light serosanguineous (pink thin fluid secreted from wounds in the healing process) drainage present. R1's Wound Physician note dated 4/17/24 shows that R1's right heel pressure ulcer was now a stage 4 pressure ulcer measuring 8.5 cm x 5 cm x 1.9 cm. […]

• Actual harm, isolatedF600Dec 3, 2023

  Based on observations, interviews and record reviews, the facility failed to protect a confused and vulnerable resident (R1) from being physically abused by a staff member and failed to follow their abuse policy by not preventing staff to resident physical abuse. This failure resulted in R1 obtaining facial injuries with noted scratches with active bleeding, swelling, pain and bruising that required the resident to be transferred emergently to a local hospital for further evaluation. […]

• Actual harm, isolatedF684Jun 15, 2023

  Based on interview and record review, the facility failed to immediately inform a physician of abnormal labs prior to a resident's change of condition of 4/03/2023 for one of thirty residents (R3) in the sample. This failure resulted in R3 having to be hospitalized due to acute hypoxemic respiratory failure, seizures, and hypernatremia. Findings Include: R3 is a [AGE] year old female who was originally admitted to the building on 7/26/2012 and still currently resides in the facility. […]

• Actual harm, isolatedF684Aug 4, 2022

  Based on observation, interview, and record review, the facility failed to carry out physician's orders related to the use of a hand splint and therapy carrot (Splints/carrot prevents further contracture) for one (R7) of one resident reviewed for restorative nursing. This failure resulted in R7's left hand contracture deteriorating from moderate to severe contracture. Findings include: R7 is a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/01/2022 at 11:30 AM, R7 was observed in bed, awake, has trouble speaking and unable to verbalize needs. His left elbow was observed stiff and flexed. His left hand/wrist was also stiff, clenched into a fist and the fingers are curled inward. […]