Federal inspectors found Aperion Care DeKalb violated treatment requirements for two residents during a December complaint investigation, with staff skipping documented wound care on multiple occasions between November and December.
The most serious case involved a resident with dementia, diabetes, heart failure and an antibiotic-resistant organism infection. His left leg displayed a venous stasis ulcer measuring 7.5 centimeters by 2.0 centimeters and 0.1 centimeters deep — roughly three inches long and nearly an inch wide. A second wound on his right leg measured 2.0 by 1.5 centimeters.
Doctors ordered daily wound treatments starting October 16, including cleansing, ointments, oil emulsion dressings and gauze wraps for both legs. But treatment records showed no documentation of care on November 3, 16, 20, 25 and 28.
The pattern continued into December. Staff failed to document wound treatments on December 11, 12 and 16. Progress notes contained no treatments recorded for those dates and no explanations for the missing care.
A second resident experienced similar gaps in wound treatment. He developed a skin tear on his left foot in early November, followed by another tear on his left knee in December. Both wounds measured roughly one centimeter.
His doctor ordered wound care three times weekly — Monday, Wednesday and Friday — including saline cleansing, oil emulsion dressing and bordered dressings. Treatment records showed missing documentation on December 12 and 15 for both wounds.
"Sometimes they are too busy to get to my wound treatments," the resident told inspectors on December 19.
Director of Nursing V2 acknowledged the documentation failures during interviews. She explained that wound care should be recorded on treatment administration records when completed.
"If the resident refuses, he or she should educate and make another attempt, then document the refusal," V2 told inspectors. "If the wound care is not documented on the TAR there is no proof the wound care was completed."
V2 emphasized the importance of consistent wound care for healing, infection prevention and wound assessment opportunities.
The facility's wound care policies were requested during the inspection but never provided to investigators.
Venous stasis ulcers like the one affecting the diabetic resident typically result from poor circulation in the lower legs. Without proper treatment, such wounds can worsen, become infected or fail to heal entirely. For diabetic patients already fighting antibiotic-resistant infections, missed wound care carries heightened risks.
The inspection occurred on December 24 following a complaint. Investigators reviewed nursing care and wound treatment for 13 residents, finding violations affecting two patients.
Both residents required ongoing wound management for injuries that developed while living at the facility. The diabetic resident's ulcer had persisted for months, while the second resident developed his first skin tear in November, followed by the knee injury weeks later.
Federal regulations require nursing homes to provide treatment and care according to physician orders and resident needs. The missed treatments violated these requirements, inspectors determined.
Staff documentation gaps prevented verification of whether treatments actually occurred on the missing dates. Without recorded evidence, regulators cannot confirm residents received ordered medical care.
The diabetic resident's case proved particularly concerning given his multiple health conditions. Diabetes impairs wound healing, while antibiotic-resistant infections complicate treatment options. Heart failure can further compromise circulation, making consistent wound care critical.
For the second resident, repeated skin tears suggested potential underlying issues requiring careful monitoring and prompt treatment. The December knee injury occurred while his foot wound was still healing.
Missing wound treatments can lead to complications including delayed healing, increased infection risk, deeper tissue damage and potential hospitalization. For vulnerable nursing home residents with multiple health conditions, such gaps in care pose serious consequences.
The facility has not yet submitted its correction plan to address the violations. Federal inspectors classified the harm level as minimal but noted the potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Dekalb from 2025-12-24 including all violations, facility responses, and corrective action plans.