Aperion Care Dolton

Inspectors wroteBased on observation, interview, and record review the facility failed to keep residents free from misappropriation of funds. This deficiency affected three residents (R1, R2, R3) of eight residents reviewed for misappropriation of funds. This past noncompliance occurred from 3/23/2026 through 3/25/2026. Prior to the survey date of 3/31/26, the facility had taken the following actions to correct the noncompliance:On 3/24/26, the facility Compliance Assurance Committee developed a plan of correction for the 3/23/26 R1, R2, and R3 misappropriation of funds. On 3/24/26 All staff received an education in- service on Abuse Prevention Policy, Abuse reporting, resident rights, proper handling of funds and financial exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician order for anticoagulation medication. This deficiency affected one (R5) of nine residents reviewed for physician orders. This past noncompliance occurred on 2/11/2026. Prior to the survey date of 3/31/26, the facility had taken the following actions to correct the noncompliance:On 2/11/26, the facility Compliance Assurance Committee developed a plan of correction for the 2/11/26 R5's readmission physician orders. On 2/11/26 All staff received an education in- service on following and carrying out physician orders, 5 rights of medication administration, medication administration and verification of new admission/readmission orders. On 2/11/26, the facility completed a facility wide audit of the past 60 days to ensure physician orders have been carried out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag to maintain resident's right to privacy and dignity. This failure affected one resident(R3) of two residents, reviewed for privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag did not rest on the floor directly, to prevent potential contamination of the drainage bag from the floor surface. This failure affected one resident (R3) of two residents reviewed for indwelling urinary catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (R1, R2, and R5) were properly placed on enhanced barrier precautions, staff were adequately informed of isolation procedures and failed to follow their infection precaution guideline procedure. This failure has the potential to affect all 14 residents currently residing on the South-2 Unit.

Inspectors wroteBased on interview and record review the facility failed to securely store a resident's injectable medication for 1 of 3 residents (R1) reviewed for medication storage in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise a resident who is at risk for aspiration and requires staff assistance during meals (R3) and failed to provide adequate staff supervision for a resident during smoking (R4). These failures affected two (R3, R4) of four resident reviewed for accidents and supervision and resulted in R3 sustaining an injury during mealtime, while in her room unsupervised and required treatment of two sutures; R4 was found on the floor while out on the patio, unsupervised, during a smoke break and required transfer to local hospital for evaluation of swelling to forehead.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse from a resident (R4) with a history of sexual inappropriate behaviors. This applies to 1 of 2 residents (R3) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to protect the resident right to free from mental abuse by staff when needing assist. This affected one of three residents (R1) reviewed for abuse. V1 told R1 that she would not fit in the shower chair. This failure results in R1 feeling dehumanized and humiliated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during blood sugar check for one (R59) of two residents reviewed for blood sugar monitoring. The facility also failed to empty and cover a urinary collection canister for one resident (R329) of eight residents reviewed for dignity in a sample of 20 residents. Findings Include: During medication administration on 3/21/24 at 12:00pm with V4 (Registered Nurse) performed blood sugar check on R59 with a resident and family member sitting opposite R59 in the 400-hall dining area. R59's room was being cleaned at the time blood sugar check was due. On 3/21/24 at 12:30pm, V4 stated that the blood sugar check should have been done in a private area to provide privacy to R59. On 3/21/24 at 1:42pm, V2(Director of Nursing) stated that all patients should be provided privacy during blood sugar check. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide professional standards of care by failing to prime an insulin Flex pen prior to administering insulin to one resident (R59) of two residents reviewed for insulin administration in a sample of 20 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide grooming for three residents (R5, R25, and R57) of eight residents reviewed for activities of daily living in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its infection control policy by failing to disinfect an intravenous tubing valve for 30 seconds for one (R330) of one resident reviewed for intravenous medication administration in a sample of 20 residents.

Inspectors wroteBased on interview and record review the facility failed to offer pneumococcal immunization to one resident (R57) of five residents reviewed for immunizations in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check placement of a gastric tube immediately before starting a feeding for one (R3) of two residents reviewed for gastric tube feedings in the sample of three.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services for care of a resident with a clinically justified indwelling catheter that affected 1(R1) of 3 residents in the sample of 3 reviewed for catheter care. This failure resulted in R1's emergent transfer to an acute care hospital where resident was diagnosed and treated in the ICU for septic shock and injury to the urethra.

Inspectors wroteBased on interview and record review, the facility failed to place effective fall prevention interventions to include monitoring to reduce or prevent the risk of falling for a cognitively impaired resident with a behavior of getting out of bed unassisted. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident suffering resulting in a hematoma to the left eye. Findings Include: R1 is an [AGE] year-old with the following diagnosis: Alzheimer's Disease, Dementia, and Adult Failure to Thrive. A Fall note dated 12/5/23 documents around 4:35 AM R1 was found in R1's room on the floor. The physician was notified and ordered to send R1 out to the hospital for an evaluation. The ambulance arrived around 7:15 AM. R1 was alert but confused. A large hematoma to the left eye was noted. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed label insulin and eyedrops with an opened or use by date and to remove expired medications from two of two medication carts reviewed for medication storage. This failure has the potential to all insulin dependent residents and residents who are prescribed eyedrops. Findings Include: On 12/21/22 at 4:10pm the North medication cart contained opened and used insulins that did not have an opened or used by date. R50's insulin lispro 3 ml (milliliter) vial, R40's insulin lispro 3 ml two vials, R55's insulin lispro 10 ml vial, R34's insulin lispro 10 ml vial, insulin glargine pen injector, R22's insulin regular human 10 ml vial, R9's insulin lispro 10 ml vial, insulin glargine 10 ml two vials. V17 (LPN-licensed practical nurse) stated, insulins are good for thirty days. The date should be on them when they are opened. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff respected the resident's private space by knocking on the door and requesting permission to enter one resident's room (R18) out of three reviewed for respect/dignity in a sample of 20. This facility also failed ensure R18's urinal was emptied after use.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean, homelike environment for one resident (R64) out of three reviewed for cleanliness of room in a sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to place an inner cannula at the bedside for one resident (R66) of three residents reviewed for tracheostomy (delivers oxygen to the lungs if the patient is unable to breath) management in a sample of 20 residents.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to follow physician orders and adequately monitor blood sugar levels before meals for 2 residents (R18 and R53) of three residents reviewed for diabetic management in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on dating opened food items in refrigerator cooler area for 71 of 76 residents who receive meals from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility to keep the call light in reach for one resident (R56) of eight residents reviewed for accommodation of needs in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to notify the doctor or nurse practitioner and to document the notification for low Phenytoin (Dilantin) level for one patient (R73) reviewed for physician notification.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care for one resident (R33) of eight residents reviewed for activities of daily living in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the doctor order for safe medication administration for one patient (R73) observed for Medication Administration.

Inspectors wroteBased on observation, interview and record review the facility failed to follow medication storage policy, failed to write the open date and expiration dates on insulin vials, insulin pens, eye drop, tuberculin purified (Aplisol) vials, and inhaler once opened and failed to remove expired medications from the medication carts. This deficiency was observed in one medication cart and one medication room reviewed for medication storage.