Inspection Reports for
Aperion Care Evanston

The complaint was substantiated. The resident reported not receiving morning medication on 12/25/2025 and feeling unsafe due to rude staff and lack of nursing presence until after breakfast.

The facility failed to ensure the resident felt safe and did not follow its Residents Rights Policy. One resident reported not receiving medication on time and feeling unsafe due to staff behavior and lack of nursing presence.

The complaint involved a resident (R1) who was transferred to the hospital involuntarily without prior notification or proper documentation. The resident was verbally aggressive, and the facility failed to follow protocols for behavior management and communication with the resident and responsible parties. The complaint was substantiated based on interviews and record reviews.

The facility failed to follow its discharge and change in resident condition policies by not informing the resident in advance of a planned hospital transfer, failing to obtain a physician's order for the transfer, and failing to document the transfer in the medical record. The resident was verbally aggressive towards staff and other residents, and the facility did not properly document behaviors or communications with the resident and responsible parties.

The complaint investigation found substantiated verbal abuse between two residents (R1 and R2) involving name-calling in English and Spanish. The abuse was ongoing, with staff attempts to redirect failing during the incident weekend. One resident exhibited aggressive behavior leading to hospital transfer and police involvement.

The facility failed to prevent and protect residents from verbal abuse, specifically name-calling related to weight between two cognitively intact residents. Staff reported ongoing verbal altercations, and the situation escalated to the point where one resident required hospital evaluation after aggressive behavior.

The complaint involved allegations that resident R2 verbally abused resident R3 by making racial slurs and referring to R3 as a slave. The facility failed to investigate or report the abuse allegation to the State Survey Agency. The complaint was substantiated by interviews and record review.

The facility failed to protect residents from abuse, failed to timely report the abuse allegation to the State Survey Agency, and failed to investigate the abuse allegation. The incident involved verbal abuse and racial slurs by resident R2 towards resident R3, causing emotional distress. No formal investigation or report was initiated by the facility.

The complaint investigation was substantiated based on observations, interviews, and record reviews confirming staff did not knock before entering rooms despite resident requests and posted signs.

The facility failed to adhere to residents' rights to privacy by staff not knocking on doors before entering rooms. This issue affected two residents who reported concerns and was confirmed by observation and interviews.

The facility was found deficient in multiple areas including failure to refer a resident for appropriate PASARR Level II evaluation, improper oxygen administration and storage, failure to discard expired medications, inadequate food safety practices including improper utensil sanitization and food labeling, failure to monitor resident refrigerator temperatures, and lapses in infection control practices related to transmission-based precautions.

The complaint investigation found that fall prevention measures were not properly implemented for one resident. The resident was noncompliant at times, and the facility was unaware of the wheelchair brake issue. The resident was unable to recall details of the most recent fall.

The facility failed to ensure fall prevention measures were consistently in place for one resident, including a non-functional call light, improperly positioned fall mat, and a wheelchair brake that did not fully lock. These deficiencies posed a minimal harm or potential for actual harm to the resident.

The complaint investigation included allegations of abuse by staff towards resident R3, failure to provide privacy during insulin administration, medication errors, failure to post nurse staffing, improper medication storage, inadequate food preparation hygiene, lack of arbitration agreement disclosures, and failure to offer required immunizations. The abuse allegation was not reported due to the administrator's belief that the resident had a history of making false allegations.

The facility was found deficient in multiple areas including failure to ensure resident privacy during insulin administration, failure to report and investigate an abuse allegation, failure to post daily nurse staffing, medication errors in insulin dosing, improper labeling and dating of inhalers and insulin, inadequate hand hygiene during food preparation, failure to inform residents about binding arbitration rights, and failure to offer influenza and pneumococcal immunizations to a resident.

The investigation was complaint-driven due to an incident where resident R1 fell and sustained burns from contact with a radiator. The immediate jeopardy was identified and removed after corrective actions were implemented.

The facility failed to provide a hazard-free environment by allowing R1 to be exposed to a hot radiator surface after a fall, resulting in second-degree burns requiring hospitalization. The immediate jeopardy was removed after the facility implemented a removal plan including protective radiator covers and enhanced monitoring.

The facility failed to ensure a female resident was shaved and free of facial hair as required by the care plan and facility policy. The resident had prominent facial whiskers and lacked assistance with shaving despite needing help with personal hygiene.

The complaint investigation revealed that the facility lacked a full-time Director of Nursing and failed to provide adequate behavioral health services to a resident (R1) who exhibited aggressive behaviors and refused medications. The behavioral health company had limited contact with the resident, and staff often left the resident alone during outbursts.

The facility failed to employ a designated full-time Director of Nursing and failed to provide adequate behavioral health care for a resident with psychosocial adjustment difficulties, resulting in minimal harm or potential for harm to residents.

The investigation was triggered by a complaint regarding an incident on 02/16/23 where resident R1 wandered into resident R2's room, was pushed, fell, and sustained a fracture. The complaint was substantiated with findings of inadequate supervision and staffing issues during breaks.

The facility failed to provide adequate supervision and monitoring of a cognitively impaired resident who wandered into another resident's room, resulting in a fall and a comminuted displaced right femoral neck fracture requiring surgical repair. Staffing shortages during breaks contributed to inadequate monitoring and failure to prevent the incident.

The facility failed to store drugs and biologicals according to accepted professional practices, including unsecured pre-prepared medications stored improperly under the medication room sink. Disciplinary action was taken against the nurse responsible.