Aperion Care Oak Lawn

Inspectors wroteBased on the interview and record review, the facility failed to protect the resident's right to be free from misappropriation of resident property by having the resident's bank card stolen by a facility staff member and used without authorization. This applies to 1 of 3 residents (R1) reviewed for misappropriation/exploitation in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate notification was provided for a room change for one (R3) resident of three residents reviewed for resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy by failing to ensure appropriate hand hygiene was performed during incontinence care for one (R3) resident of three residents reviewed for improper nursing care related to infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their storage of medication policy by having opened, used, expired medication for four of four residents (R87, R19, R105 and R95) reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its food service and sanitation policies by not ensuring milk was maintained at a temperature of at least 45 degrees Fahrenheit during meal service, failing to discard outdated bread observed with a green substance, failing to ensure the sanitizing solution was maintained at the appropriate concentration, and failing to use clean water when cleaning food carts. This deficient practice had the potential to affect all 118 residents who receive food prepared by the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to follow their care plan policy and ensure that the care plan accurately reflects the resident advance directives to not be resuscitated, and failed to obtain a physician order and document R111's code status in her electronic medical record this affects two of three residents (R46 and R111) reviewed for advanced directives. Findings Include:1. R46's physician order sheet dated [DATE] denotes do not resuscitate. R46's Illinois Department of Public Health uniform practitioner order for life sustaining treatment (POLST) form dated [DATE] denotes no CPR: do not resuscitate (DNAR), signed by R46's agent under power of attorney and provider. R46's face sheet denotes R46 has a guardian the name is the same as the noted on the POLST form. [...]

Inspectors wroteBased on interview and record review the facility failed to protect a resident from a resident-to-resident physical assault when R120 pushed R106 to the floor. This affected two (R106, R120) of four residents reviewed for physical abuse. Findings Include: R120's Minimum Data Set/MDS date 12/22/25 shows BIMS score of 15. On 1/13/26 at 11:52am R120 observed alert to person, place, time and situation. R120 said a male resident came to his room looking her his roommate (R34). R120 said he told the resident that he could not come in the room. R120 said he got out his bed and pushed the resident down to the floor. R120 said the resident was standing at the doorway when he pushed the resident to the floor. R120 said he don't know who the male resident was that he pushed to the floor. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy and prevent and protect a resident from staff to resident misappropriation of resident property. This failure affected one resident (R38) out of three reviewed for theft in a sample of 50. In September 2025 R38's credit card was taken by a staff member, and purchases/cash advances were made without R38's permission.

Inspectors wroteBased on interviews and record reviews, this facility failed to follow its abuse prevention policy and report an allegation of staff to resident theft to the State Surveying Agency within the required timeframe. This affects one resident (R38) out of three residents reviewed for reporting theft in a sample of 50.

Inspectors wroteBased on interview and record review, this facility failed to follow its abuse prevention policy and conduct a thorough investigation, prevent further theft from occurring, and take appropriate corrective action for an allegation of theft involving one resident (R38) out of three residents reviewed for abuse prevention in a sample of 50.

Inspectors wroteBased on interview and record review the facility failed to follow their practice to ensure that the Minimum Data Set assessment is accurately coded for four of four residents (R2, R46, R106, R116) reviewed for accuracy of MDS assessments.

Inspectors wroteBased on interview and record review, the facility failed to follow their incontinence care policy by not providing incontinence care for over two hours for a resident as requiring substantial/maximal assistance with incontinent care. This affects one of three residents (R124) reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision of a resident while smoking on the patio. The resident was identified as requiring supervision during smoking. This affected one of three residents (R22) reviewed for safe smoking monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its urinary care policy by not ensuring a resident's indwelling urinary catheter drainage bag was kept off the floor. This affected one of three residents (R72) reviewed for urinary catheter and infection control practices

Inspectors wroteBased on interview and record review, the facility failed to follow its weight assessment and intervention policy by not conducting a reweight within 24 hours after a significant weight loss was noted. This deficient practice affected one of three residents (R88) reviewed for nutrition and weight loss prevention.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to report an injury of unknown origin for a resident who was dependent on staff for Activities of Daily Living (ADLs). This failure affected one resident (R1) of three residents reviewed for injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to initiate and thoroughly investigate an injury of unknown origin for a resident who is dependent on staff for Activities of Daily Living (ADLs). This failure affected one resident (R1) of three residents reviewed for injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a home like environment by not implementing an effective remedy to fix a leaking toilet, that caused water damage to the wall in the residents' room. This affects 4 of 4 (R3, R4, R9, R6) residents reviewed for sanitary home like environment.

Inspectors wroteBased on observation, interview and record review the facility failed to have an effective pest control program/policy for treatment of flying pest. This affected two of two residents reviewed for pest control practice. This failure has the ability to affect all resident utilizing the dining room.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy procedures and prevent a resident-to-resident physical abuse. This affected two of five residents (R3, R4) reviewed for abuse. This failure resulted in R4 slapping R3 in the face after R3 backed into R4 with a wheelchair.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse by another resident for 1 of 3 residents reviewed for abuse. This failure resulted in R2 being sent out to the local hospital and sustaining a human bite to the right forearm and required treatment of antibiotics. This deficiency is past non-compliance that occurred from 5/17/2025 to 5/22/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from accident hazards, by not using the mechanical lift for a dependent resident transfer for 1 (R1) of 3 residents. This failure resulted in R1 sustaining a non-displaced oblique fracture through the lateral plateau of the right tibia and fibula. R1 was transferred to the local hospital and underwent a surgical procedure on 5/15/2025. This deficiency is past non-compliance that occurred from 5/13/2025 to 5/15/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for nail care by failing to observe the condition of R2's toenails during weekly skin assessments and bathing, failed to document observations, and failed to provide podiatry services for one (R2) of three residents reviewed for foot care. This failure resulted R2 developing Onychomycosis, toe pain, toenail dystrophy with Onycholysis, subungual debris, and painful elongated toenails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were dependent on staff for care were provided with showers according to the facility protocol and residents' preference. This failure applied to eight (R1, R2, R3, R4, R6, R7, R9, and R12) of twelve reviewed for showers during the month of March 2025.

Inspectors wroteBased on interview and record review the facility failed to ensure resident safety by failing to have two staff members present when providing a mechanical lift transfer. This failure affects one (R4) of three residents reviewed for fall prevention program.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and employee handbook by having a staff member accept gifts that were purchased by a resident. This affected one of three residents (R2) reviewed for abuse. Findings Include: R2 is a [AGE] year-old with the following diagnosis: cerebral palsy, paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and bipolar disorder. The Police Report dated 10/22/24 documents R2 related that R2 is lending money to V12 (Certified Nursing Assistant/CNA) at the facility and that it was a verbal agreement. This is civil in nature. There are no other details on what gifts were given to the staff member or the amount of money. The Facility Reported Incident dated 10/22/24 documents R2 alleged that V12 misappropriated resident funds. R2 stated R2 was upset that V12 was not available to be the assigned CNA. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Food Storage (Dry, Refrigerated, and Frozen) Policy by not labeling 2 bowls of gelatin with the date which has the capacity to affect 109 residents on an oral diet. The facility also failed to maintain resident personal refrigerators which affected 2 of 2 residents (R42 and R106) reviewed for refrigerators of a total sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure no intravenous medication and hazardous pesticides were left at resident's bedside. The facility also failed to follow physician order in implementing fall precaution measures. This deficiency affects all four (R10, R23, R37 and R52) residents in the sample of 30 reviewed for Residents' safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of oxygen & respiratory equipment. The facility also failed to ensure proper hand hygiene/handwashing is performed during resident care. This deficiency affects all eleven (R15, R23, R38, R42, R50, R52, R85, R93, R105, R124, R432) residents in the sample of 30 reviewed for Infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to respond promptly to an activated call light for one of three residents (R33) reviewed for call light in a sample of 30. The facility also failed to ensure to knock before going inside the resident's room for one of one resident (R50) observed for privacy and dignity in a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents call light was within reach for 2 of 4 residents (R10 and R232) reviewed for accommodation of needs in a sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the advance directive is indicated in the resident's health records for one of one resident (R1) reviewed for advanced directives in a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standard care practice of utilizing minimal layer of linens and not utilize a disposable brief when using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R10) of three residents in the sample of 30 reviewed for pressure ulcer management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician order is followed for tube feeding administration. This deficiency affected 1 of 3 residents (R121) reviewed for tube feeding administration in a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one (1) of two (2) medication storage rooms and one (1) of three (3) medication carts reviewed for Medication Storage.

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent one resident who was identified as moderate risk for skin breakdown and is totally dependent on staff for all ADLs (activities of daily living), from developing three facility-acquired pressure ulcers. The facility also failed to provide the necessary care and services upon admission to promote healing of a left hip stage 2 pressure ulcer. This affected one of three residents (R1) reviewed for pressure sore. This failure resulted in R1 developing three facility-acquired pressure ulcers (unstageable wounds) including the coccyx area, right hip, and right lateral foot. R1's stage 2 wound to the left hip deteriorated to an unstageable wound.

Inspectors wroteBased on interview and record review, the facility failed to prevent residents from experiencing neglect inflicted by a Certified Nursing Assistant. This failure applied to two (R3, R4) of three residents reviewed for abuse and neglect and resulted in R3 and R4 being knowingly left in soiled incontinence briefs for multiple hours by staff. R3 reported that R3 was having severe discomfort due to incontinence causing R3's skin to burn in sites of open skin areas. R4 stated he felt unappreciated, like a stepchild and left in the corner.

Inspectors wroteBased on interview and record review, the facility failed to ensure the building's call light system was operational. This failure affected 26 residents residing on the North Hall Unit of the facility.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse and neglect. This failure affected two (R3 and R4) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility to ensure a resident was treated with dignity and respect for 1 of 3 residents (R5) reviewed for dignity in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to ensure a venous doppler ultrasound was performed in a timely manner for a 1 of 3 residents (R3) reviewed for quality of care in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a gait belt was applied while transferring a resident safely. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered and not left at the bedside. This applies to 1 of 3 residents reviewed for medication administration in the sample of 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R1) reviewed for incontinence care. This failure resulted in R1 observed being soaked with urine through her pants, skin redden with indentations. Findings Include: R1's brief interview for mental status dated 4/26/24 documents a score of 15/15 which indicated cognitively intact. R1's minimum data set section H bowel and bladder dated 4/26/24 under urinary incontinence documents always incontinent. On 8/1/24 at 3:22PM, R1 who was assessed to be alert and oriented to person, place, and time, said, she was soaking wet. R1said, she had not received incontinence care since 6:00am when she got up to the wheelchair. V8 (Certified Nursing Assistant/CNA) and V9 (CNA) was observed providing R1's incontinence care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the Centers for Diseases Control and Prevention (CDC) practices for Covid-19 by not requiring the appropriate use personal protective equipment (PPE) for residents on contact/droplet precautions and in isolation. This affected two of two residents (R10, R11) reviewed for infection control. Findings Include: R10's hospital paperwork dated 7/29/24 documents: R10 presented on 7/26 with altered mental status (AMS) now found to have Covid. Isolation: Contact, Droplet Infection. R10's face sheet documents: Covid-19. Physician order sheet dated 8/1/24 documents: Strict Isolation-Droplet and contact precaution-Covid +, every shift for ten days. R10's care plan dated 8/1/24 documents: I have a Covid Infection. [...]

Inspectors wroteFailures at this level required more than one deficient practice statements. I. Based on interview and record review, the facility failed to monitor and supervise a resident with cognitive impairment, identified as high fall risk with a history of falls and decreased safety awareness. This affected one of three residents (R4) reviewed for falls and supervision. This failure resulted in R4 having two unwitnessed falls which resulted in a small subdural hematoma and a hematoma to right side of forehead. R4's diagnosis includes Vascular Dementia and Altered Mental Status. Brief interview for mental status dated 4/11/24 documents a score of five which indicates severe cognitive impairment. Fall risk assessment dated [DATE] documents: at risk for falls. Care plan dated 2/9/24 documents: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their incontinence care policy for one resident who was identified as dependent on staff for assistance with toileting. This failure resulted in R3 being cold, wet, and uncomfortable in urine. This affected one of three residents reviewed for incontinence care. Findings Include: R3 has the diagnosis of vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left dominant side. Brief interview for mental status dated 4/5/24 documents a score of fifteen which indicate cognitively intact. Section GG (functional abilities) documents: R3 was dependent for toileting hygiene (helper does all the effort) resident does none of the effort to complete activity. R3's care plan dated 3/17/22 documents: he has bowel and bladder incontinence. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders by not drawing weekly Keppra levels and failed to follow pharmacy recommendations for administrating Keppra tablets by crushing the tablets for one (R6) of three residents reviewed for medications and physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure utility rooms were maintained in a safe, clean, and sanitary condition. This has the potential to affect all the facility staff and residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of misappropriation of controlled medications for 1 of 3 residents (R3) reviewed for misappropriation in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure controlled substances were administered, documented, and reconciled appropriately for 1 of 3 residents (R3) in the sample of 8.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for fall prevention by not ensuring that interventions were in place per the resident's plan of care for a resident at risk for falls and they failed to ensure that a resident who is at risk for falls due to wandering and impaired safety awareness was adequately monitored to prevent injury. These failures applied to two (R24 and R95) of three residents reviewed for falls and resulted in R24 obtaining a lumbar spine fracture while receiving care and R95 not receiving adequate supervision to determine the cause of superficial skin tears and bruising.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for safe and sanitary food service by not ensuring kitchen area and surfaces are clean and free of contamination, not properly storing dried food, not properly storing food handling equipment, not properly wearing hair restraints, not performing hand hygiene when necessary, and not measuring cooked food temperatures. This failure has the potential to affect all 122 of 125 residents in the facility who receive their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly care and treat one resident with a urinary catheter and prevent development of repeated urinary tract infections. This failure applied to one (R59) of one resident reviewed for incontinence care.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure that staff follow their medication administration policy of ensuring that resident have their medications available as ordered and failed to ensure that staff do not borrow medications from one resident to another. The facility also failed to properly document medication administration of medication(s) on the controlled drug records for residents. This failure affected five residents (R35, R65, R91, R102 and R115) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately date open insulin pens and multi-dose insulin vials, and dispose of expired insulin for 7 (R13, R29, R53, R82, R111, R114 and R131) of seven residents reviewed during the medication storage and labeling observation. The facility failed to ensure a medication was stored in the pharmacy container with the pharmacy label while on the medication administration cart and failed to maintain the medication refrigeration temperature log to record temperatures daily. These failures have the potential to affect 31 residents on (name of unit) including the 7 residents who receive insulin.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's lost clothing was recovered and failed to reimburse a resident's family for the missing clothing as documented in the grievance form. This failure affected one (R51) of two residents reviewed for personal property.

Inspectors wroteBased on interview and record review, the facility failed follow their policy and procedure for bathing residents as scheduled. This failure applied to one (R85) of one resident reviewed for assistance with activities of daily living.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for monitoring constipation for a resident with a history of constipation and fecal impaction. This failure applied to one (R2) of 26 residents reviewed for nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their pressure ulcer prevention policy by not immediately assessing an alteration to the residents' skin. This failure applied to one (R1) of three residents reviewed for pressure ulcers and resulted in a delay of four days before R1's skin was assessed after skin alteration was identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were four medication errors out of 28 medication opportunities resulting in a 14% medication error rate. This failure affected two (R81, R115) residents reviewed during the medication administration task.