Aperion Care Forest Park

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse administering the medications observed the resident while taking the medications, failed to ensure medications were administered one hour after the scheduled time, and failed to document medication administration after administering medications to the residents. These failures affected 6 (R5, R6, R7, R8, R9, and R10) residents reviewed for medication administration in the total sample of 13 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff do not leave the resident's EHR (electronic health record) open when unattended. This failure affected 1 (R3) resident reviewed for confidentiality of record in the total sample of 13 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were disposed of where resident could not accessed them. This failure affected 1 (R12) resident reviewed for hazard and supervision in the total sample of 13 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff don and doff gloves appropriately in an effort to prevent the cross contamination. This failure affects 1 (R5) resident reviewed for infection control during medication administration in the total sample of 13 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide care and maintain hygiene for resident's nails for two of three residents (R3 and R8) reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents (R7) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure essential equipment Mechanical lift is in working condition, by not inspecting a Mechanical lift on the 3rd floor with exposed inner cords from charging cord. This has the potential to affect all residents residing on the 3rd floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's room environment was in good repair related to ceiling tiles not being replaced upon falling for two of two residents (R1, R2) reviewed for environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a comfortable and homelike environment, failed to have a readily available and adequate supply of clean bed and bath linens for residents to perform daily hygiene, bathing, or showers, failed to provide adequate lighting in resident rooms, and failed to ensure a mattress was provided on the bed frame and the bed was made with linen and a pillow for a resident that transferred into a room. This failure affected four residents (R38, R43, R94, and R158) out of a sample of 67 residents and has the potential to affect all 199 residents residing at the facility reviewed for a clean and comfortable homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to report an alleged violation involving a resident-to-resident verbal/mental abuse. This failure affected one (R7) of two residents reviewed for abuse in a total sample of 67.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to initiate and thoroughly investigate an allegation of resident-to-resident verbal/mental abuse. This failure affected one (R7) of two residents reviewed for abuse in a total sample of 67.

Inspectors wroteBased on interview and record review, the facility failed to obtain from an outside resource routine and emergency dental services. This failure affected one (R210) resident reviewed for dental services in the total sample of 67 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light devices were placed within residents' reach. This failure affected two (R6 and R7) residents reviewed for call light devices in the total sample of seven residents.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan after each fall. This failure affects one (R5) resident reviewed for care plan in the total sample of 7 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their abuse prohibition policy by failing to conduct a thorough investigation for an injury of unknown origin. This failure affects one of three residents (R1) reviewed for injuries of unknown origin. As a result, R1 was noted with swelling to the right lower forearm and grimacing in pain and was transported to the local hospital and R1 was found to have sustained a right comminuted distal radial fracture with displacement, a comminuted and impacted distal ulnar fracture with displacement, and a hematoma to the right side of the head.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure adequate supervision and proper use of assistive devices for one wheelchair dependent resident (R1) of three residents reviewed, resulting in an injury requiring urgent transport to the hospital for an acute comminuted femur fracture. This past non-compliance occurred from 07/29/2025 to 08/05/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's comfort by failing to provide a comfortable mattress resulting in R1 lying in a sunken mattress. This failure affect one of three residents (R1) reviewed for comfortable mattresses.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's safety while providing incontinence care. This failure affects one of three residents (R2) reviewed for falls in a total sample of six residents. This failure resulted in R2 sustaining left leg fracture to the tibia and right leg fracture to the femur, requiring hospitalization. The past non-compliance occurred from 05/5/2025 to 05/13/2025.

Inspectors wroteBased on interview and record review, the facility failed to provide accepted standards of clinical practice by failing to provide necessary care and services in administering necessary medications, failed to identify signs and symptoms of hypotension, and failed to notify the RN and physician before having dialysis treatment. This failure affects 1 (R2) of 3 residents reviewed for professional standards in the sample of 3.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its physician orders policy and hypoglycemia guidelines and administer emergency medication to treat a resident exhibiting signs and symptoms of severe hypoglycemia (low blood sugar level) for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently. The immediate jeopardy began on 2/21/25 when R1 was found unresponsive and with a blood glucose level of 29. V1 and V2 were notified of the immediate jeopardy on 03/13/2025 at 9:35 AM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow professional standards of nursing care and clarify with the physician the frequency and route of administration of insulin 70/30 prior to administering the medication. This failure affected one resident (R1) out of three reviewed for significant medication errors in a sample of 4. Prior to admission, 20 units of insulin 70/30 was administer to R1 subcutaneously once a day. The order was changed on 2/19/25 at 00:50 AM to insulin 70/30, administer 20 units intramuscularly three times a day. This resulted in R1 having severe hypoglycemia with a blood sugar level of 29 and being nonresponsive for unknown length of time. The immediate jeopardy began on 2/21/25 when R1 was found unresponsive and with a blood glucose level of 29. V1 and V2 were notified of the immediate jeopardy on 03/13/2025 at 9:35 AM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its physician - family notification - change in condition policy and notify the attending physician/nurse practitioner of a resident having severe hypoglycemia and obtain emergent treatment orders. This failure affected one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. On 2/21/25, R1 was nonresponsive and with a blood sugar level of 29; no treatment initiated prior to EMS (emergency medical services) 911 arrived and transported R1 to the hospital emergently.

Inspectors wroteBased on interviews and record reviews, the facility to provide quality care and services in accordance with professional standards of practice for blood sugar monitoring, insulin administration, recognizing the signs and symptoms of hypoglycemia, and implementing interventions to treat hypoglycemia for one resident (R1) out of three residents reviewed for diabetes management in a sample of 4. This failure resulted in R1 receiving intermediate-acting insulin on 2/21/25 at 11:31 AM and 12:19 PM leading to severe hypoglycemia with a blood sugar level of 29.

Inspectors wroteBased on interview and record review the facility failed to notify a residents Power of Attorney for healthcare (POAH) of a fall with injury that required Emergency treatment for 1 of 3 residents (R1) reviewed for notification of change in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure treatment orders were initiated for a resident with a stage 2 sacral pressure ulcer. This applies to 1 of 3 (R3) residents reviewed for pressure ulcers in the sample of 5.

Inspectors wroteBased on interview and record the facility failed to ensure a resident was free from significant medication errors by failing to ensure admission medications were transcribed and administered for 1 of 3 residents (R3) reviewed for medications in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure discarding food products before or on expiration date affecting all 196 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators have recorded temperature logs affecting 4 of 6 (R6, R53, R140, R168) residents reviewed for resident refrigerator in a sample of 36. Findings Include: 1. On 1/14/2025 at 6:20AM, during kitchen initial tour, the container of multiple use for Flour, Thickener, and Sugar has the used by date of 9/24/2024. All containers were less than half full. V21 (Cook) said it was recently filled but forgot to change the date on the label. V21 said yesterday was the last time the content of these containers was used. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects 5 (R11, R102, R148, R191, R261) of 5 residents in the sample for 36 reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement manufacturer's recommendation in using low air loss mattress to residents with multiple stage 4 and unstageable pressure ulcer. This deficiency affects all four (R5, R83, R147 and R185) residents in the sample of 36 reviewed for Wound/Pressure ulcer Prevention Management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall preventive measures were implemented to residents who are at risk for fall and history of falls. The facility also failed to change the fall intervention with each fall incident in a timely manner. This deficiency affects all four (R147, R148, R191 and R261) in a sample 36 reviewed for Fall prevention program.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor self-administration medication management, medication refrigerator temperature log, and label insulin with open date and follow pharmacy/manufacturer's recommendation on discarding for one of five medication carts (3rd floor medication cart), and one of two medication room storage (2nd floor medication room) observed for medication storage and labeling. This failure also affected one of one resident (R4) reviewed for medication self-administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to knock on resident's doors before entering for three of 36 (R5, R62, R207) reviewed for dignity in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R68) reviewed for abuse in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to a dependent resident. This deficiency affects one (R55) of three residents in the sample of 36 reviewed for Activity of Daily Living (ADL) Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's order for oxygen administration affecting 1 of 2 (R53) residents reviewed for oxygen use in a sample of 36. Findings Include: On 01/14/25, at 8:05 AM, R53 was in bed with oxygen (O2) on per nasal cannula (NC) running at 1L per minute. Physician order checked with V4 (Licensed Practical Nurse/LPN) and indicated O2 at 2L/NC and titrate to 4L/NC. V4 said R53's oxygen should be at 2L/NC. On 1/14/2025 at 8:32 AM, V2 (Director of Nursing) said physician's orders should be followed and O2 in use signage should be posted by the door. Order Summary Report: Diagnoses: Metabolic Encephalopathy; Respiratory Failure, Unspecified with Hypoxia; Shortness of Breath; Unspecified Asthma, Uncomplicated; [...]

Inspectors wroteBased on record review and interview the facility failed to ensure that each resident medication regimen was free from unnecessary medication for 1 of 2 resident's (R91) reviewed for unnecessary psychotropic medication in a sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to use appropriate infection control practices after using respiratory treatment and when performing high contact resident care to resident on Enhanced barrier precaution. This deficiency affects two (R83 and R261) residents in the sample of 36 reviewed for Infection control Program.

Inspectors wroteBased on interview and record review the facility failed to follow their policy to report the final written report of their abuse investigation to the state department within 5 working days of the reported incident for 9 of 11 residents (R1, R2, R3, R4, R5, R6, R7, R7, R9) reviewed for reporting final investigation.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from resident to resident physical abuse. This failure affects four of four residents (R1, R2, R3 R4) reviewed for abuse. This failure resulted in R1 getting feces thrown in R1's eye and on R1's body. This physical abuse caused R1 to feel upset, disgusted, abused, and scared R4 would throw more and R4 would try to attack R1.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of resident to resident abuse for two residents (R1, R4) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the involuntary discharge notice to the ombudsman. This deficiency affects one (R9) of three residents reviewed for transfers and discharges. Findings Include: R9 is a [AGE] year-old, female, originally admitted in the facility on 07/25/24 with diagnoses of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizophrenia, Unspecified; Bipolar Disorder, Unspecified; and Schizoaffective Disorder, Bipolar Type. MDS (Minimum Data Set) dated 07/29/24 recorded R9's BIMS (Brief Interview for Mental Status) of 9, which means moderate impairment in cognition. Involuntary transfer/discharge notice dated 11/14/24 was issued to R9 due to safety of individuals in the facility is endangered. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement an individualized and person-centered care goals and services addressing maladaptive behavior; and failed to establish appropriate activities and therapy programs for a resident diagnosed with mental disorder. This deficiency affects one (R9) of one resident reviewed for behavior and behavior management.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention interventions for one of three (R1) residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two residents who roomed together were compatible. This applies to 2 of 3 (R1, R5) residents reviewed for resident rights in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms, and the dining room were in a clean, sanitary condition for 2 of 3 residents (R1, R3) reviewed for clean, comfortable, homelike environment in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders for a urinalysis was completed for 1 of 3 residents (R2) reviewed for laboratory services in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents are treated in a dignified manner by using personal cell phones while monitoring residents for 4 (R6, R8, R12, R13) of 6 residents reviewed for resident's rights in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to have a written policy to address the response to an opioid overdose and failed to ensure that staff were trained and competent in monitoring of a resident after administration of Narcan medication. The facility also failed to follow recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration) for the administration and monitoring of a resident assessed to be at risk for substance abuse and who received Narcan medication for a suspected overdose. This failure affects one of one (R11) resident reviewed for overdose treatment. These failures resulted in R11 not being monitored in accordance with SAMHSA recommendations after receiving Narcan while in the facility for a suspected overdose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility is maintained in a clean and sanitary condition by failing to provide a clean, homelike environment. These failures have the potential to affect all 209 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents on two different floors. This failure affects 147 residents who reside on the third and fourth floors and has the potential to affect all 209 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that their facility assessment included a thorough evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the day-to-day needs of the residents. This failure affects has the potential to affect all 209 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers to residents dependent on staff assist with bathing and failed to provide timely incontinence care to residents requiring staff assistance. These failures affect three of three (R4, R8, R10) residents reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a supply of resident medication was available as prescribed by the physician for 2 of 4 residents (R1, R14) reviewed for medications in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received their anticonvulsant medication immediately following a hospitalization for status epilepticus (prolonged seizure activity) for 1 of 4 residents (R4) reviewed for medications in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment by not adequately assessing, monitoring or supervising residents at risk for falls for 4 of 5 (R1, R3, R4, R5) reviewed for falls; and failed to follow their fall prevention program by not ensuring fall interventions were securely in place for a resident (R1) with a history of and risk for falls. These failures resulted in R1 falling and being hospitalized for laceration to the left ear; R3 falling and being hospitalized for laceration to the left eyebrow; R4 falling and being hospitalized for right femur fracture with surgical repair; and R5 falling and being hospitalized for left femur fracture.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to accurately transcribe a physician's order for pain medication and failed to follow facility's medication administration policy by not clarifying the pain medication dosage for one (R4) of two residents reviewed for medications.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R2) of 4 residents in the sample (R1, R2, R4 and R5) from physical abuse inflicted by his roommate (R3). This failure caused R2 to be struck with a metal rod multiple times to the face resulting in an emergent transfer to the hospital for treatment of his injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow advanced directives for DNR (Do Not Resuscitate) orders and Emergency Code Blue procedures for 1 (R1) of 5 residents in the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall prevention interventions were implemented, failed to update fall prevention care plans and implement new post fall care interventions. The facility also failed to document monitoring of residents at a risk for falls. These failures affect five of five residents (R1-R5) reviewed for a history of falls with injuries on the sample list of five.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe storage of resident's medication by leaving medication at bedside. The facility also failed to date inhalers, eyedrops and insulin when opened and discard after 28 days. The facility also failed to refrigerate unopened eyedrops. This deficiency affects all ten residents (R47, R52, R60, R67, R123, R151, R163, R217 and R267) in the sample of 36 reviewed for Medication storage.

Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy by not closing the privacy curtain or the room door while administering insulin for one resident (R118) of four reviewed for resident's rights in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform nail care and follow get up list schedule for three of five residents (R180, R95, R60) reviewed for activities of daily living (ADL) care in a sample of 36.

Inspectors wrote2. R195 is admitted on [DATE] with diagnosis listed in part but not limited to Anoxic brain, Encephalopathy, Contractures of left and right elbow, Acute and chronic respiratory failure. Physician order sheet indicates: Skilled OT (occupational therapy) services 3-5x weeks for 41 days includes any combination of interventions including: Splint assessment and management. Care plan indicates at risk for limited range of motion related to anoxic brain damage. No interventions in placed for range of motion and splint management. Occupational Therapy (OT) evaluation and plan of treatment for certification period of 8/16/23 to 9/28/23 indicates: Goals: Patient will safely wear hand splint on and an elbow extension splint on right elbow and right wrist. OT Discharge summary dated [DATE] indicated: Discharge recommendation for functional maintenance program: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and follow it's smoking safety policy for a smoking resident (R179), one of five residents reviewed for smoking in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to check for gastrostomy tube (GT) placement prior to administer enteral feeding and follow physician order for enteral feeding. This deficiency affects one (R195) of three residents in the sample of 36 reviewed for Enteral/Tube feeding Management.

Inspectors wroteBased on observation, interview and record review the facility failed to keep a tracheostomy tube and an obturator at bedside for resident with tracheostomy tube. This deficiency affects one (R95) of three residents in the sample of 36 reviewed for Tracheostomy care management.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy on infection control in storing Nebulizer (Handheld breathing mask) in a plastic bag after completing breathing treatment. The facility also failed to keep the tracheostomy oxygen corrugated tubing and water collection drainage bag off the floor. The facility also failed to implement appropriate standard cleaning and disinfecting of glucometer after use. These failures have the potential to affect four residents (R72, R149 and R195) reviewed for infection control in a sample of 36 residents.

Inspectors wroteBased on interview and record review the facility failed to prevent the overdose of illicit drugs at the facility for 5 of 12 residents (R1, R2, R3, R12, and R9) reviewed for substance abuse on the sample list of 13. This failure resulted in an immediate jeopardy. The immediate jeopardy began on [DATE] at 11:23 PM when R1 and R2 who were roommates, were both found unresponsive. R2 required CPR, Narcan, and emergency services. R1 required Narcan and emergency services. On [DATE] at 1:15 PM, R3 was found unresponsive and required Narcan and emergency services. On [DATE] at 4:02 PM, R12 required Cardiopulmonary Resuscitation (CPR), Narcan, and emergency services and again on [DATE] at 1:30 PM, R12 required Narcan and emergency services. All incidents were related to the use of illegal substances. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:55 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure administration operationalizes and oversees facility's policies and procedures regarding substance abuse to ensure the safety of residents with a history of substance abuse. This failure resulted in a delayed response to the facility's substance abuse issue and resulted in 5 residents (R1, R2, R3, R9, and R12) overdosing on illegal substances and requiring Narcan administration, emergency services, and in some cases CPR.

Inspectors wroteBased on interview and record review the facility failed to ensure a reasonable suspicion of a crime was reported for 5 of 12 residents (R1, R2, R3, R9, and R12) reviewed for illegal substance possession and use on the sample list of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to provide clean and organized closet for resident clothing. This deficiency affects two (R1, R2) of three residents reviewed for home like environment on the sample list of five.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions for two of three residents (R2, R5) reviewed for falls on the sample list of five.

Inspectors wroteBased on observation and interview the facility failed to repair a resident's bed to ensure it was in safe operating condition. This failure affects one (R1) of three residents reviewed for safety on the sample list of five.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to follow their dialysis cleaning and maintenance policies by not ensuring dialysis chairs are kept clean and in good repair. This failure includes 8 residents (R8, R62, R64, R74, R87, R104, R133, R188) in a total sample of 40 residents reviewed for environment and applies to all 18 residents receiving dialysis treatment in the facility.