Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Monroe during CMS and state inspections, most recent first.
A pork loin was observed thawing in the bottom of a 3-compartment sink with running water flowing onto the meat, but it was not submerged. The Dietary Mgr stated the cook should have used a deep pot, and the facility policy said thawing under cool running potable water is only for emergencies and food items should be completely submerged.
Failure to obtain informed consent for psychotropic medication changes. Two residents with diagnoses including dementia, depression, anxiety, psychosis, and schizoaffective disorder had psychotropic meds increased, including lorazepam, Cymbalta, and Zoloft, but the clinical records lacked documentation that the resident and/or resident representative were informed of the treatment options, risks, and benefits. The DON confirmed informed consent had not been obtained before the medication increases, despite facility policy requiring it.
Failure to Notify Physician and Representative of Significant Weight Loss: A resident with schizophrenia and HTN had a significant weight loss documented on the nutrition record, but the chart lacked timely documentation that the physician or responsible party was notified. The resident was on a mechanical soft diet with added foods, and progress notes did not show notification until a later CCRC meeting, after the weight loss had already been identified.
A resident with dementia, Alzheimer's disease, and a sacral pressure ulcer was sent to the hospital for a bleeding sacral wound and underwent wound surgery to stop the bleeding. The discharge MDS remained in process and incomplete, and the DON stated the facility was aware of the incomplete assessment and corporate staff was working to complete it.
A resident with traumatic brain injury and major depressive disorder had an active order for Alprazolam for anxiety, along with documentation showing an active anxiety diagnosis and use of anti-anxiety meds. However, the Quarterly MDS did not mark anxiety as an active diagnosis. The DON confirmed the MDS should have been marked yes, and the Administrator stated the facility used the RAI tool to complete MDS assessments.
Failure to provide ordered nutritional supplement: A cognitively intact resident with schizophrenia and HTN had significant recent weight loss and was care planned for nutritional risk with supplements as ordered. Observations showed the resident’s lunch tray repeatedly lacked the ordered ice cream supplement, and the Dietary Manager later stated she forgot to place it on the tray.
A facility failed to provide the required written notification for a transfer and discharge to a resident and their representative. The resident, diagnosed with dementia and a femur fracture, was hospitalized, but the clinical record lacked documentation of the notification. The Administrator claimed the forms were sent, but this was not documented, and the facility's policy did not include this requirement.
A facility failed to provide written notification of its bed hold policy to a resident or their representative after a hospital transfer. The resident, diagnosed with dementia and a femur fracture, was transferred without documented communication of the policy. The Administrator claimed the forms were sent but not documented, contrary to the facility's policy requiring notification at transfer or within 24 hours in emergencies.
The facility inaccurately coded MDS assessments for two residents regarding their nutritional status. One resident's significant weight loss was not correctly documented, while another resident was incorrectly reported to have received IV nutrition instead of enteral feeding. The facility lacked a specific MDS coding policy, relying on the RAI manual.
A facility failed to label medications with open and expiration dates in the medication room. A vial of tuberculin PPD and an Ozempic injector pen for a resident were found without these dates. The DON could not find the dates and was unsure about the discard time frame for opened medications. The facility's policy required staff to follow manufacturer guidelines and record the date opened.
A resident with Type II Diabetes Mellitus did not receive a carbohydrate-controlled diet as prescribed, leading to weight gain. The resident reported receiving high-carb meals, contrary to hospital discharge orders for a low-carb diet. The facility's administrator admitted the diet order was incorrectly entered upon admission, failing to follow the policy requiring confirmation of diet orders.
A facility failed to protect a resident from misappropriation of property when an LPN diverted the resident's controlled substance for personal use. The incident was discovered after a discrepancy in the narcotic count, which had not been performed as required by facility policy. The resident had multiple medical conditions and was prescribed oxycodone for pain management.
Improper Thawing of Meat in Kitchen
Penalty
Summary
The facility failed to ensure food was prepared in accordance with professional standards for food service safety when a large pork loin was observed thawing in the bottom of a three-compartment sink with running water flowing onto the meat. The meat was not submerged in water and the water was flowing down the drain. During interview, the Dietary Manager stated the cook should have had the meat in a deep pot while the water was running onto it. The facility policy provided by the Administrator stated that thawing foods under cool running potable water is not recommended and should only be used in an emergency if the food is cooked immediately, and that food items should be completely submerged under running water.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to ensure that residents were informed of and participated in their treatment for two residents reviewed for unnecessary medications. Resident 7 had diagnoses including schizoaffective disorder, psychosis, generalized anxiety disorder, major depressive disorder, and dementia. The record showed orders for lorazepam 1 mg twice daily and Cymbalta increased to a total of 90 mg daily, with a psychiatry note stating the Cymbalta increase was due to the resident refusing all other medications for depressive disorder and the Ativan increase was for generalized anxiety. The clinical record did not contain documentation that informed consent was obtained from the resident and/or the resident representative regarding the treatment options, risks, and benefits of the psychotropic medication increases. Resident 33 had diagnoses including dementia and major depressive disorder. The record showed an order for sertraline (Zoloft) 100 mg once daily, and a psychiatry note stated the resident's major depressive disorder was persistent as evidenced by irritability and that Zoloft was increased to 100 mg daily. The clinical record lacked documentation that informed consent was obtained from the resident and/or the resident representative regarding the treatment options, risks, and benefits of the psychotropic medication increase. The DON confirmed during interview that informed consent had not been obtained prior to the increases in psychotropic medications, and the facility policy stated psychotropic medications shall not be administered without informed consent and that side effects and dosage shall be described.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the resident’s representative and physician were notified of a significant weight loss for Resident 25, who had diagnoses including schizophrenia and hypertension. The resident’s weights showed 156 pounds on 6/3/25, 144 pounds on 7/9/25, and 140 pounds on 7/28/25, reflecting a 7.69% loss in one month. The care plan identified the resident as nutritionally at risk due to schizophrenia and directed staff to report significant weight loss of 5% or greater in a month to the physician and to weigh and record the resident as ordered. The Nutrition Progress note dated 7/10/25 documented the 7.7% weight loss and noted the resident was on a mechanical soft diet with ice cream at lunch and dinner and double eggs at breakfast, but it did not document notification of the responsible party or physician. Progress notes from 7/6/25 through 8/6/25 also lacked documentation of such notification. The record did not contain a Comprehensive Clinical Review meeting dated 7/16/25, and the Comprehensive Clinical Review Meeting dated 7/23/25 indicated the responsible party and nurse practitioner were notified 14 days after the significant weight loss. During interviews, the DON stated the responsible party would be notified after the first weekly Comprehensive Clinical review meeting, and later stated the resident’s June weight was 156 pounds and the 7/9/25 weight was 142 pounds, while the record still lacked documentation of notification until 7/23/25.
Incomplete Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure staff submitted a comprehensive MDS assessment within 14 days of a resident's discharge for Resident 13. The resident's clinical record showed diagnoses including dementia, Alzheimer's disease, and a sacral pressure ulcer. A progress note dated 7/17/25 stated the resident was sent to the hospital for a bleeding sacral wound and was admitted after wound surgery was performed to stop the bleeding. The discharge MDS assessment for 7/17/25 was listed as "in process" and incomplete, and the ARD was 7/17/25. During interview, the DON stated the facility was aware of the incomplete MDS assessment and that corporate staff was working to complete it.
Inaccurate MDS Assessment for Anxiety Diagnosis
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident reviewed for MDS accuracy. The resident had diagnoses including traumatic brain injury and major depressive disorder, and the clinical record showed an active physician order for Alprazolam for anxiety, along with a provider progress note documenting an active diagnosis of anxiety and a care plan noting use of anti-anxiety medications. However, the Quarterly MDS assessment dated 6/30/25 did not mark anxiety as an active diagnosis. During interview, the DON stated the resident had an active anxiety disorder on 6/30/25 and acknowledged the MDS should have been marked yes for anxiety disorder. The Administrator stated the facility did not have a MDS policy and used the RAI tool to complete MDS assessments. The RAI Manual indicated anxiety disorder status is based on a 7-day look-back period and ongoing therapy with medications or other interventions.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure a resident received the nutritional supplement ordered for a resident with documented weight loss. Resident 25, who had diagnoses including schizophrenia and hypertension and was cognitively intact on the quarterly MDS, reported losing weight in the prior month. The resident’s weights showed 156 pounds on 6/3/25 and 144 pounds on 7/9/25, reflecting a 7.69% weight loss in one month. The care plan identified the resident as at nutritional risk due to schizophrenia and directed staff to provide supplements as ordered. The Nutrition Progress note dated 7/10/25 stated the resident was on a mechanical soft diet with ice cream at lunch and dinner and double eggs at breakfast. However, on multiple observations, the resident’s lunch tray did not have ice cream, and the resident stated he did not get ice cream on his lunch tray. On 8/6/25, the resident’s lunch tray again did not have ice cream until the Dietary Manager was observed placing a dish of ice cream on the tray and stated she forgot it. The facility policy provided by the Administrator lacked documentation of nutritional supplements.
Failure to Provide Written Notification for Transfer and Discharge
Penalty
Summary
The facility failed to provide the required written notification for a transfer and discharge to both the resident and the resident representative for a resident who was hospitalized. The clinical record of the resident, who had diagnoses including dementia and a fracture of the left femur, was reviewed and found to lack documentation of the written notification of the transfer and discharge forms. The resident was sent to the hospital, but there was no evidence that the necessary documentation was provided to the resident or their representative. During an interview, the Administrator stated that the forms were sent in writing to the resident representative, but this was not documented. Additionally, the facility's policy on Discharge Transfer of Resident did not include the requirement to send written notification to the resident and the resident representative.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident or the resident's representative following a transfer to the hospital. This deficiency was identified during a review of the clinical record for a resident with diagnoses including dementia and a fracture of the left femur. The resident was transferred to the hospital, but the clinical record did not contain documentation that the bed hold policy was communicated in writing to the resident or their representative. During an interview, the Administrator stated that the forms were sent in writing but acknowledged that this was not documented. The facility's policy requires that the bed hold policy be given to the resident or representative at the time of transfer, or within 24 hours in cases of emergency transfer.
Inaccurate MDS Assessments for Nutrition
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents regarding their nutritional status. For one resident with Alzheimer's Disease, the clinical records showed a significant weight loss of 12.93% over five months, with weights recorded from 116 pounds to 101 pounds. However, the Annual MDS assessment inaccurately reported the resident's weight as 134 pounds and failed to assess the weight loss during the look-back period. The Assistant Director of Nursing confirmed the incorrect coding during an interview. For another resident with traumatic brain injury, dysphagia, and respiratory failure, the Admission MDS assessment inaccurately indicated the resident received Parenteral/IV nutrition. However, the physician's orders and interviews with the Director of Nursing and the Assistant Director of Nursing/MDS Coordinator confirmed that the resident only received enteral feeding and never had IV feedings. The facility did not have a specific MDS assessment coding policy and relied on the Resident Assessment Instrument (RAI) manual for guidance.
Failure to Label Medications with Open and Expiration Dates
Penalty
Summary
The facility failed to properly label medications with open and expiration dates in the medication room, as observed during a survey. Specifically, a vial of tuberculin PPD and an Ozempic injector pen for a resident were found without open or expiration dates. The Director of Nursing (DON) was unable to locate these dates on the medications and acknowledged that all opened medications should have such dates. Furthermore, the DON was uncertain about the appropriate time frame for discarding medications after they have been opened. The facility's policy on Medication Storage, dated July 2, 2019, was reviewed, which indicated that staff should follow manufacturer guidelines for expiration dates and record the date opened on the medication container.
Failure to Provide Carbohydrate-Controlled Diet
Penalty
Summary
The facility failed to provide a resident with a carbohydrate-controlled diet as prescribed by the physician, resulting in a deficiency. Resident 35, who has a diagnosis of Type II Diabetes Mellitus, reported receiving meals high in carbohydrates despite being on a low-carb diet during a previous hospital stay. The resident mentioned receiving meals such as ham salad on bread and chicken and noodles, which were not suitable for his dietary needs, leading to weight gain since his admission to the facility. Upon review, it was found that the physician's orders from 9/1/24 to 9/30/24 indicated a regular diet, which contradicted the hospital discharge orders dated 9/27/24 that specified a low-carb diet. The facility's administrator acknowledged that the diet order was incorrectly entered upon the resident's admission, and the facility's policy required nursing staff to confirm diet orders using standard terminology before recording them in the health record. This oversight resulted in the resident not receiving the appropriate diet as prescribed.
Misappropriation of Resident's Controlled Substance
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of property through the diversion of a resident's controlled substance for staff use. The incident involved Resident B, who had a prescription for oxycodone-acetaminophen due to multiple medical conditions including sarcopenia, hemiplegia, pain disorder, and major depressive disorder. On the morning of 3/2/24, the MDS Coordinator received a report from an LPN that two cards of oxycodone were missing. Subsequent urine drug screens revealed that one LPN tested positive for oxycodone, oxymorphone, and oxycodone/oxymorphone, indicating potential misuse of the resident's medication by staff. The missing medication was discovered during a reconciliation process on 3/2/24 after it was noted that the narcotic count had not been performed on 3/1/24 by the oncoming and off-going shift nurses as required by facility policy. The clinical record review for Resident B showed that the resident had received a shipment of 174 tablets of oxycodone on 2/26/24, which were counted and logged by staff until 3/1/24 when the count was not performed. The discrepancy was discovered on 3/2/24 when staff attempted to reconcile the medication count and found that two cards of oxycodone were missing. Interviews with various staff members revealed that the required narcotic counts were not consistently performed, and there was a lack of adherence to the facility's policy on counting controlled substances. The Director of Nursing confirmed that the policy required oncoming and off-going shift nurses to count narcotic medications together to ensure accuracy. Further investigation included reviewing written statements from staff members, which indicated lapses in the narcotic counting process. One LPN admitted to not performing the oncoming narcotic count on 3/1/24, and another staff member noted discrepancies in the medication cards and narcotic sheets. The facility's policies on narcotic counting and residents' rights were reviewed, highlighting the requirement for staff to count controlled substances with a partner and verify the accuracy of the log sheets. The failure to adhere to these policies resulted in the misappropriation of Resident B's medication, compromising the resident's right to be free from the wrongful use of their belongings or money.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hearthstone Health Campus | 0.3 mi | ★★★★★ | 3 | 0 |
| Brickyard Healthcare - Bloomington Care Center | 1.4 mi | ★★★★★ | 1 | 1 |
| Bell Trace Health And Living Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Majestic Care Of Bloomington | 2.8 mi | ★★★★★ | 5 | 0 |
| Stonecroft Health Campus | 4.1 mi | ★★★★★ | 0 | 0 |
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