F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on interview and record review the facility failed to securely store a resident's injectable medication
for 1 of 3 residents (R1) reviewed for medication storage in the sample of 3.
The findings include:
R1's Face Sheet shows a diagnosis of acute transverse myelitis in demyelinating disease of central nervous
system.
On 2/21/25 at 10:50 AM, V6 (R1's Family Member) said that she delivered three doses of R1's Enspryng
injection that she had delivered to her home from a specialty pharmacy to the facility. V6 said that she
received a call from the nurse on 2/7/25 and the nurse said that they could not find her third dose of the
injection. V6 said that R1 was sent to the emergency room but was not able to receive the medication but
they re-ordered the medication for her and the resident received the dose on 2/12/25.
R1's Medication Administration Record (MAR) for January and February shows an order for: Enspryng
Subcutaneous Solution Prefilled syringe 120 mg (milligrams)/ML (milliliter)-Inject 120 mg/ml
subcutaneously in the afternoon every 2 weeks on Friday for neuromyelitis for 6 weeks. R1's January MAR
shows that she received a dose on 1/10/25 and 1/24/25. R1's February MAR shows that she was supposed
to get a dose on 2/7/25 but received it on 2/12/25.
R1's Nursing Note dated 1/10/25 shows, Approached by [V6] in facility regarding order for Enspryng Three
available injections in frig (refrigerator) as per [V6] she brought 3 injections
R1's Nursing Note dated 2/7/25 shows, Reached out to [V6] regarding need for Enspryng Subcutaneous
Solution Prefilled Syringe. Patient is due for administration this afternoon. None available. Per pharmacy is
a specialty medication. Daughter provided last doses. She was made aware of need for medication at this
time.
On 2/21/25 at 10:39 AM, V3 (Licensed Practical Nurse) said that she was R1's nurse on the day that she
needed her third injection. V3 stated that V6 had brought three doses of the injection, and they were put in
the medication room refrigerator. V3 stated that they were in separate boxes and had R1's name on them.
V3 stated that she administered R1's first and second dose of the medication but the day that her third
injection was due, she could not find it in the fridge. V3 stated that she notified V6, V2 (Director of Nursing)
and R1's Nurse Practitioner.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145877
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145877
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Dolton
14325 South Blackstone
Dolton, IL 60419
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 2/21/25 at 12:38 PM, V2 (Director of Nursing) said that she was notified by V3 that she could not find
R1's Enspryng injection. V2 stated that she searched the medication room and facility and could not find
the injection. V2 stated that she then called V6 and told her that she thinks that the medication got thrown
out in error.
A Concern Form dated 2/7/25 for R1 shows, Staff reached out to family that a dose of Enspryng injection is
missing for [R1] Summary of Pertinent Findings: Substantiated Facility was searched not able to locate. Pt
(patient) monitored, sent out to hospital. No adverse reaction. Physician notified
On 2/21/25 at 1:59 PM, V1 (Administrator) stated that the facility does not have a policy for when family
brings in medications for the resident.
The facility's undated Storage of Medication Policy shows, Medications and biologicals are stored safely,
securely, and properly, following manufacturer's recommendations or those of the supplier.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145877
If continuation sheet
Page 2 of 2
