Aperion Care Chicago Heights

Inspectors wroteBased on observation interviews and record reviews, the facility failed to follow a physician order for enhanced barrier precaution (EBP) for one resident and failed to follow their enhanced barrier precaution policy by failing to ensure that staff wear appropriate personal protective equipment (PPE) while providing wound care. This failure affected one (R4) of seven residents reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R2) was free of physical abuse by another resident (R1) for two out of three residents reviewed for abuse in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency for one out of three residents reviewed for abuse reporting in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy by not matching residents' diet orders to food trays during meal service, and failed to have a system in place to ensure that the prescribed diet was served and ensured tray accuracy (that each resident receives food that is prepared in a form designed to avoid allergies and meet each individual's needs and preferences). These failures have the potential to result in residents receiving the wrong diet and can affect all 139 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that: food carts were free of dried food spills; the floor of the dry storage room was kept clean and free of visible dirt, and the wall air vent return was free of accumulated dust. These failures have the potential to affect all 139 residents that receive oral foods from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the outside dumpster garbage disposal was covered with the lids and failed to ensure that the floor around the dumpsters were free of bags of trash and spilled trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 139 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff sanitize the tables in the dining area in between residents and failed to ensure that residents were assisted with hand hygiene before eating. This failure has the potential to affect all 139 residents currently residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure and failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 139 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure handrails to the corridor walls. This failure has the potential to affect all 139 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that five residents (R52, R64, R93, R119 and R136) had a clean and sanitary bathroom. This failure affected a total of five residents reviewed for resident's rights to enjoy a clean, homelike environment, in a total sample of 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their comprehensive care plan policy by failing to develop a person centered care plan for a resident to include measurable objectives and timeframes to meet the resident's medical and nursing needs that were identified in the comprehensive assessment for Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia for one (R20) resident of 54 residents reviewed for care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff carry out physician orders and failed to ensure that resident received ordered medications for his skin condition. This failure affected one (R2) of one resident reviewed for skin condition in a total sample of 54.

Inspectors wroteBased on interview and record review the facility failed to provide care in accordance with professional standards for medication administration during an emergency crisis when one resident (R1) was found unresponsive and administered insulin. This failure affected one (R1) of four residents reviewed for medication administration and has the potential to affect 43 residents identified as having diagnosis of Diabetes Mellitus in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by failing to protect residents from physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by not reporting an allegation of physical abuse to the state agency. This failure applies to two of three residents (R1 and R2) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by not investigating an allegation of physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their Physician's Order Policy by failing to discontinue medication as ordered by the physician. This deficient practice affects one resident of three residents reviewed for medication administration. This failure resulted in R3 receiving extra dosages of antiepileptic medication. Findings Include: R3 admitted in the facility on 2/28/25. R3 has a diagnosis of Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizure. R3 admitted in the facility with medications such as, but not limited to: Brivaracetam 100mg (milligrams) two times daily for seizure, Clobazam 10mg at bedtime for seizure, Divalproex Sodium 500mg two times daily for seizure, and Levetiracetam (Keppra) 750mg two times daily for seizure with order date of 2/28/25. R3's Neurology note dated 5/6/25, reads in part: [...]

Inspectors wroteBased on interviews and records review, the facility failed to administer medications to one (R1) of three residents reviewed for medication administration in a total sample of six.

Inspectors wroteBased on interview and record review the facility failed to follow the discharge policy and give a copy of notice to discharge to the resident representative for one of three residents (R1) reviewed for discharge notice.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident abuse to the State Survey Agency for two of two residents (R292 & R105) reviewed for abuse in the sample of 39 residents. Findings including: On 1/6/25 at 10:30 AM, survey team requested V1 (administrator and abuse prohibition coordinator) all reportable incidents within the last 90 days. V1 presented the survey team with 3 incidents reported to public health regional office (RO) however did not have the incident of 12/18/24 involving R292 and R105. On 1/7/25 at 11:15 AM, V1 (administrator) stated to survey team that the incident on 12/18/24 involving R292 did not warrant reporting as it did not involve another peer (resident). Surveyors asked who was involved in the incident altercation, V1 indicated that R292 struck the CNA V19. [...]

Inspectors wroteBased on interview and record, the facility failed to follow their policy by failing to notify the responsible party for a resident when the resident was discharge to the hospital. This failure affected one of three (R1) residents reviewed for notification on the sample list of six. Findings Include: On 11/21/24 at 1:50pm, V10 (R1's guardian) said, she was not notified when R1 was discharged to the hospital. On 11/22/24 at 10:17am, V29 (nurse) said, all of R1's paperwork and notifications were done prior to her shift. V29 said, her duty was to wait to the hospital to call to accept R1, call the ambulance to pick up and send R1 to the hospital. V29 said, she would call the family after the resident has been admitted to the hospital. V29 said, R1 was not admitted to the hospital prior to the end of her shift. R1 was under observation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from misappropriation of his property. This applies to 1 of 3 residents (R1) reviewed for abuse/misappropriation in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse. This deficiency affects all four (R29, R81, R103 and R192) residents in the sample of 27 reviewed for Abuse prevention Program.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered for 1 of 3 residents (R135) reviewed for medication administration in a sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a functional Eyewash Station where hazardous chemicals are used. This deficiency affects all units, reviewed for environmental safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (R4) reviewed for abuse in the sample of 11 was free of resident to resident physical abuse.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy for facility maintenance by not ensuring handrails were installed in a manner that was nonhazardous to residents. This failure affects four of four residents (R1, R2, R3 and R4) reviewed for environment on the sample list of five.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for administering medications by not ensuring a resident's medication was available for administration, not ensuring the resident received their own personally prescribed medication, not documenting the administration of the resident's medication in their medical records. This failure applied to one of four residents (R1) reviewed for medication administration on the sample of five.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide to the residents a safe and comfortable home-like environment that supported and enhanced each resident's overall quality of life by not maintaining an effective housekeeping and preventative maintenance plan due to the overall visibly uncleaned and unkept appearance the resident living areas, missing and/or visibly damaged railings and baseboards, walls and floors visibly stained with brown to black colored stains throughout resident common areas, resident rooms, dining room, bathrooms and hallways throughout unit one, and the presence of black flying insects within the hallway and main kitchen area. This failure directly affected three residents (R1, R2, R3) and cumulatively affects all 123 residents who currently reside at the facility.