F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:R20 is [AGE] years of age. Current diagnoses include but are not
limited to Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula,
Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia.R20's
comprehensive assessment section C Cognitive Patterns dated 01/14/2025 documents a brief interview for
mental status score of 15 which indicates R1 is cognitively intact.On 01/27/2026 at 2:25 PM, V21 MDS
(Minimum Data Set) Coordinator was inquired of R20 not having a care plan for his medical diagnoses. V21
said, R20 has Anemia, Type 2 Diabetes, Hypertension, and Elevated Cholesterol. He's taking medication
for them. He's on Metformin for his diabetes, Carvedilol for hypertension, and Atorvastatin for cholesterol. I
don't see it on his care plan. He should have a care plan so the caregiver knows what's going on and how
to give care for what his diagnosis are and what care he should be receiving.R20's admission
comprehensive assessment section I active diagnoses dated 10/02/2025 documents his medical conditions
in part as Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia.R20's admission [DATE]
and current January 2026 care plans do not document his medical conditions of Anemia, Type 2 Diabetes
Mellitus, hypertension, and Hyperlipidemia.R20's medication administration record documents the following
physician ordered medications to be administered- Sodium Chloride tablet 1 gram by mouth three times a
day related to anemia start date 9/26/2025. Carvedilol oral tablet 6.25mg (milligrams) give 1 tablet by mouth
two times a day related to hypertension start date 9/26/2025. Hydralazine HCI (Hydrochloride) 10mg oral
tablet give 1 tablet by mouth every 6 hours as needed for elevated blood pressure related to hypertension
start date 9/26/2025. Metformin HCI (Hydrochloride) oral tablet 500mg give one tablet by mouth two times a
day related to type 2 diabetes mellitus start date 9/26/2025. Atorvastatin Calcium oral tablet 10mg give 1
tablet by mouth at bedtime related to hyperlipidemia start date 9/26/2025. These medications were
administered by nursing staff as prescribed by the physician from 9/26/25 through 01/29/2026.The revised
11/17/17 comprehensive care plan policy states in part:Purpose: To develop a comprehensive care plan
that directs the care team and incorporates the resident's goals, preferences, and services that are to be
furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial
well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan
for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to
meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the
comprehensive assessment.The comprehensive care plan must describe the
(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:
145180
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
145180
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Chicago Heights
490 West 16th Place
Chicago Heights, IL 60411
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
following:o The services that are to be furnished to attain or maintain the resident's highest practicable
physical, mental, and psychosocial well-beingo Any services that would otherwise be required but are not
provided due to the resident's exercise of rights, including the right to refuse treatment.A comprehensive
care plan must be-o Developed within 7 days after completion of the comprehensive assessment.o
Prepared by an interdisciplinary team, that includes but is not limited to-? The attending physician.? A
registered nurse with responsibility for the resident.? A nurse aide with responsibility for the resident.? A
member of food and nutrition services staff.? To the extent practicable, the participation of the resident and
the resident'srepresentative(s). An explanation should be included in a resident's medical record if the
participation of the resident and their resident representative is determined not practicable for the
development of the resident's care plan.? Other appropriate staff or professionals in disciplines as
determined by the resident's needs or as requested by the resident.o Reviewed and revised by the
interdisciplinary team after each assessment, including both the comprehensive and quarterly review
assessments. The CAAs provide a link between the MDS and care planning. The care plan should be
revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.
Event ID:
Facility ID:
145180
If continuation sheet
Page 2 of 2
