Aperion Care Marion: Medication Orders Ignored - IN
The resident, identified in inspection records only as Resident B, carried diagnoses of atherosclerotic heart disease with unstable angina, combined systolic and diastolic heart failure, and hypertension. A physician had ordered midodrine 5 mg to be given whenever the resident's systolic blood pressure dropped below 90. The order had been in place since March 2025.
It was not followed.
On July 1, the resident's blood pressure was 88/54. No midodrine was given. On July 11, it was 83/49. No midodrine. On July 19, it was 88/61. No midodrine. On July 24, it dropped to 73/41 in the morning, and was still 86/54 by afternoon. No midodrine was given at either reading. On August 1, it was 88/57. No midodrine. On September 8, it was 86/54. No midodrine.
Six documented readings below the threshold. Six times the medication went ungiven. The medication administration record contained no entry for any of those doses.
Resident B was moderately cognitively impaired, according to an assessment completed in August 2025, meaning the resident could not reliably advocate for their own care or notice when a prescribed treatment was being skipped.
A separate resident, identified as Resident D, received a heart rate medication called amlodipine despite a heart rate of 54 on the morning of September 9, the same day inspectors were on site. The medication had parameters specifying when it should and should not be given. The heart rate that morning was outside those parameters. The medication was given anyway.
When inspectors interviewed the nursing staff, the answers were consistent and, in their own way, damning. RN 3 said she understood the process perfectly: obtain the blood pressure and heart rate, administer the medication if the readings meet the parameters, hold it if they don't, call the physician if anything is unclear. LPN 4 said the same thing. LPN 5 said the same thing, adding that it was "important to pay attention to the orders."
The Director of Nursing said staff should have been following the parameters. She said it twice, in two separate interviews conducted thirteen minutes apart. The physician orders, she acknowledged, should have been followed, and the medications should have been given or held accordingly.
Everyone knew what was supposed to happen. Nobody had made sure it did.
The Administrator's answer stood out. Asked about the facility's policy on following physician orders, the Administrator told inspectors the facility did not have one. The facility followed federal and state guidelines, the Administrator said, but there was no internal policy governing how staff were expected to carry out what doctors ordered.
A care plan for Resident B's coronary artery disease, in place since January 2024, listed two specific interventions: give medications for hypertension and document the response, and monitor blood pressure and notify the physician of any abnormal readings. The blood pressure readings on July 1, July 11, July 19, July 24, August 1, and September 8 were all abnormal by the physician's own definition. The records contain no indication that the physician was notified on any of those dates.
The inspection was conducted as a complaint investigation on September 9, 2025. The violation was cited under the standard requiring facilities to provide care and treatment in accordance with professional standards of practice. CMS classified the harm level as minimal harm or potential for actual harm.
A systolic blood pressure of 73 is not a number that exists in a gray area. For a resident with unstable angina and heart failure, blood that is not moving adequately through the body reaches the heart last and worst. Midodrine exists in that care plan because the physician understood what those numbers meant and wrote an order to address them.
The order sat unexecuted through the summer while the resident's blood pressure kept falling.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Marion LLC from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
APERION CARE MARION LLC in MARION, IN was cited for violations during a health inspection on September 9, 2025.
A physician had ordered midodrine 5 mg to be given whenever the resident's systolic blood pressure dropped below 90.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.