Inspection·March 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: On 3/18/25 at 12:20PM, V2 (Director of Nursing) said that when alleged incident with R4 occurred V6 (Certified Nursing Assistant/CNA) had placed the Mechanical lift sling on backwards and R4 slid out onto the floor. V6 was doing a mechanical lift transfer for R4 by herself. On 3/18/25, at 12:27pm, V4 (Licensed Practical Nurse/LPN) said that he was called to the room by other staff members V5 (LPN) and V6 (CNA) and when he entered the room observed R4 on floor next to Mechanical lift machine. V4 said that Mechanical lift transfers are supposed to be a two person transfer assist. On 3/18/25 at 1:12PM, V5 (LPN) said that she was the nurse on duty for the alleged incident with R4. She heard a scream coming from R4's room and when she entered the room V5 observed R4 on the floor. R4 was with V6 (CNA) in room. V5 said the mechanical lift sling was not ripped or torn. V5 said that V6 did not ask for assistance with transfer, it was only her in the room. V5 said that when a mechanical transfer is to be done there should always be a two person assist for transfer. On 3/18/25 at 1:22PM, V6 (CNA) said that she was taking care of R4 on the day of the incident. V6 said that there was no Mechanical sling in her room not aware of what happened to her sling and used a different sling from the basement, the sling was not torn or ripped. V6 said that R4 is a two person assist for transfers and V6 did not ask for assistance when using the Mechanical lift. V6 said she works night shift and sometimes there is not enough staff to have a two-person transfer. On 3/19/25 at 10:29AM, R4 said that on alleged date of incident that V6 (CNA) put the Mechanical lift sling on backwards, when V6 lifted her up she came down, sliding off the sling onto the floor. R4 said that the lift sling was not ripped or torn, that the sling was put on backwards, said that V6 was the only one in the room doing the transfer. R4 said that there is always no help at night for transfers. R4's admission date on 5/25/24 with diagnosis listed in part but not limited to other low back pain, chronic obstructive pulmonary disease, morbid obesity, cerebral palsy, other seizures, unspecified diastolic heart failure, paraplegia, unspecified, hyperlipidemia, GERD, osteoarthritis of knee, (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: 145197 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 145197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Oak Lawn 9401 South Ridgeland Avenue Oak Lawn, IL 60453 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)