Aperion Care Arbors Michigan City failed to notify the family of Resident C when her gastrostomy tube dislodged on September 1, federal inspectors found. The tube, surgically inserted through her abdomen to provide nutrition and medications, had to be cleaned daily and covered with dressings after it came loose.
Resident C had severe cognitive deficits and couldn't move in bed or transfer without help, according to her August assessment. She suffered from flaccid hemiplegia affecting her right side, aphasia that impaired her communication, and difficulty swallowing. A care plan from 2021 documented her impaired short-term and long-term memory and decision-making abilities.
The family manages her care, the plan stated clearly.
But when nurses discovered the dislodged tube at 5:56 a.m. on September 1, they called the nurse practitioner. Nobody called the family. The nurse practitioner ordered daily cleaning with saline solution and dry dressings. A note that morning said "the resident was her own responsible party and aware."
Ten days later, the tube site had become infected.
On September 11, the facility's physician prescribed amoxicillin-pot clavulanate, a powerful antibiotic, at 875-125 milligrams twice daily for ten days. The doctor also ordered doxycycline hyclate, another antibiotic, at 100 milligrams twice daily for the same period. Again, the nursing notes indicated "the resident was her own responsible party and aware."
The first round of antibiotics didn't work.
Eleven days after that, on September 22, the nurse practitioner prescribed Levaquin, a third antibiotic, at 500 milligrams daily for seven days. The infection had persisted for nearly three weeks. Once more, staff documented that "the resident was her own responsible party."
During the October 8 inspection, the facility's nurse consultant admitted the obvious problem. The resident should not be listed as her own responsible party, she told investigators, because the family managed her care.
The facility's own records contradicted the nursing notes. Resident C's profile listed family members as emergency contacts, not herself. Her care plan from 2021 explicitly stated that family managed her care decisions due to her cognitive impairments.
Federal regulations require nursing homes to immediately notify residents, their doctors, and family members of situations that affect the resident's health. A dislodged feeding tube qualifies as such a situation. So does a persistent infection requiring multiple antibiotics.
The inspection found that staff consistently treated Resident C as capable of making her own medical decisions and receiving her own health updates. But her severe cognitive deficits, documented communication problems, and established family involvement in care management made this impossible.
For three weeks, while Resident C's feeding tube site festered and required increasingly aggressive antibiotic treatment, her family remained unaware of the medical crisis. They couldn't advocate for different treatment approaches, seek second opinions, or simply provide emotional support during a frightening health emergency.
The facility's failure extended beyond a single notification. Staff repeatedly documented the same incorrect information about Resident C's decision-making capacity across multiple medical incidents. This suggests a systemic problem with recognizing which residents can manage their own care decisions and which require family involvement.
The dislodged gastrostomy tube represented a serious medical event for someone dependent on the device for nutrition and medications. When feeding tubes become dislodged, patients risk dehydration, malnutrition, and medication errors. Infections at the insertion site can lead to more serious complications if not properly treated.
Resident C's case illustrates how communication failures can compound medical problems. While she received appropriate medical treatment for the dislodged tube and subsequent infections, her family's exclusion from these decisions violated both federal regulations and the facility's own care planning documents.
The inspection occurred following a complaint, suggesting someone eventually noticed the communication breakdown. But by then, Resident C had endured weeks of medical complications while her designated caregivers remained in the dark about her deteriorating condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Arbors Michigan City from 2025-10-08 including all violations, facility responses, and corrective action plans.
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