F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
Based 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. Findings
include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility August 2025. R38 stated
that R38 gave her credit card to V14 (Business Office Manager) for V14 to process a payment to this facility.
R38 stated that V14 returned credit card to R38 and placed card and receipt on R38's over the bed table.
R38 stated that she is bedridden and does not leave her room. R38 stated that later when she went to put
credit card back in her zippered pouch, R38 could not find credit card. R38 stated that she notified V14 that
she could not find her card. R38 stated that she does not recall if she was checking her bank account or if
the bank notified her, but there was an alert on her account for unusual activity. R38 stated that there were
two charges, one to a florist for $500.00 and one was cash withdrawal from a bank for $800.00 plus a $2.50
service fee for transaction. R38 stated that R38 was told to freeze her card so no further purchases could
be made. R38 stated that a couple of days later the police came to the facility to get her statement;
afterwards the police gave her a card with the case number on it. R38 stated that she informed the police
who she thought it could be that took her card. R38 stated that V20 (Certified Nursing Assistant/CNA) was
inquiring about how R38 picks her lucky numbers. R38 told V20 that she chooses birth dates or other
occasions. R38 stated that R38's family member has access to R38's bank account but R38 has the card.
R38 stated that the bank did reimburse her for the two charges. R38 stated that she feels unnerved by this
event. R38 stated that she has been robbed before in the community, but to think this could happen in a
nursing home in which she should be safe is scary.R38's BIMS (brief interview of mental status) score,
dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make needs known.R38's abuse/neglect
screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On 1/14/25 at 10:25 AM, V14 (Business
Office Manager) stated that when R38 informed her that her credit card was missing, V14 reported it to V1
(Administrator). V14 stated that the police were notified, and a report was made. V14 stated that the
incident occurred in September 2025. V14 stated that she assumes it was a staff member because R38
doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated that V4 (Resident Liaison) would be
the person who would know more information regarding R38's missing credit card. V1 stated that R38's
credit card was missing, R38's POA (Power of Attorney) had it. V1 stated that R38 was concerned about
the charges to her bank account. V1 stated that R38 called her bank, there were two charges not familiar to
R38. V1 stated that V4 was on phone with R38 and the bank and knows more about these charges. V1
stated that the bank reimbursed R38 for the charges. V1 stated that no reportable was made for this
event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator) stated that she reported to V15
(Social Services Director) that R38's credit card was
Residents Affected - Few
(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 6
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
01/16/2026
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)
F 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
missing. V4 stated that she called R38's bank with R38 on 10/10/25. V4 stated that the bank informed them
that the bank would investigate the pending charges on R38's card and reimburse R38 if the charges were
determined to be fraudulent. V4 stated that she does not know why a reportable was not completed for this
event.On 1/14/26 at 11:14 AM, V15 (Social Services Director) stated that she was asked to see R38
regarding missing credit card. V15 stated that V4 had done some of the investigation so she had V4 also
present during meeting with R38. V15 stated that R38's POA had the credit card. V15 stated that by the
time she followed up with R38, the bank had already reimbursed her. V15 stated that she did not speak with
R38's POA to confirm she had R38's credit card.On 1/15/26 at 1:41 PM, V27 (CNA) stated that she worked
with V20 (CNA) but does not recall any details regarding the event involving R38.R38's police report, dated
10/1/2025 at 5:06 PM, notes the police officer spoke with V1 (Administrator) via telephone. V1 advised that
he believed V20 (CNA) assigned to R38's room the day R38's card had been used at an ATM, was
responsible. V1 stated to the police officer that V20 had been assigned to another resident who had his
debit card stolen. V20 had been talking to another staff member about how he had a scam system going on
at the facility. Contact was made with R38's POA, who related she was aware of the incident, but did not
know all the details. Bank statement for R38 was sent to the police department. R38's POA notified police
officer that R38 had received her money back from the fraudulent transactions, besides the $2.50 fee from
the ATM.Abuse prevention and reporting policy, revised 10/24/2022, notes this facility affirms the right of
our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods
and services by staff or mistreatment. Misappropriation of resident property means the deliberate
misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money
without the resident's consent. Misappropriation of a resident's property means the deliberate
misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money
without the resident's consent.
Event ID:
Facility ID:
145197
If continuation sheet
Page 2 of 6
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
01/16/2026
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based 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. Findings
include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility August 2025. R38 stated
that R38 gave her credit card to V14 (Business Office Manager) for V14 to process a payment to this facility.
R38 stated that V14 returned credit card to R38 and placed card and receipt on R38's over the bed table.
R38 stated that she is bedridden and does not leave her room. R38 stated that later when she went to put
credit card back in her zippered pouch, R38 could not find credit card. R38 stated that she notified V14 that
she could not find her card. R38 stated that she does not recall if she was checking her bank account or if
the bank notified her, but there was an alert on her account for unusual activity. R38 stated that there were
two charges, one to a florist for $500.00 and one was cash withdrawal from a bank for $800.00 plus a $2.50
service fee for transaction. R38 stated that R38 was told to freeze her card so no further purchases could
be made. R38 stated that a couple of days later the police came to the facility to get her statement;
afterwards the police gave her a card with the case number on it. R38 stated that she informed the police
who she thought it could be that took her card. R38 stated that V20 (Certified Nursing Assistant/CNA) was
inquiring about how R38 picks her lucky numbers. R38 told V20 that she chooses birth dates or other
occasions. R38 stated that R38's family member has access to R38's bank account but R38 has the card.
R38 stated that the bank did reimburse her for the two charges. R38 stated that she feels unnerved by this
event. R38 stated that she has been robbed before in the community, but to think this could happen in a
nursing home in which she should be safe is scary.R38's BIMS (brief interview of mental status) score,
dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make needs known.R38's abuse/neglect
screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On 1/14/25 at 10:25 AM, V14 (Business
Office Manager) stated that when R38 informed her that her credit card was missing, V14 reported it to V1
(Administrator). V14 stated that the police were notified, and a report was made. V14 stated that the
incident occurred in September 2025. V14 stated that she assumes it was a staff member because R38
doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated that V4 (Resident Liaison) would be
the person who would know more information regarding R38's missing credit card. V1 stated that R38's
credit card was missing, R38's POA (Power of Attorney) had it. V1 stated that R38 was concerned about
the charges to her bank account. V1 stated that R38 called her bank, there were two charges not familiar to
R38. V1 stated that V4 was on phone with R38 and the bank and knows more about these charges. V1
stated that the bank reimbursed R38 for the charges. V1 stated that no reportable was made for this
event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator) stated that she reported to V15
(Social Services Director) that R38's credit card was missing. V4 stated that she called R38's bank with
R38 on 10/10/25. V4 stated that the bank informed them that the bank would investigate the pending
charges on R38's card and reimburse R38 if the charges were determined to be fraudulent. V4 stated that
she does not know why a reportable was not completed for this event.On 1/14/26 at 11:14 AM, V15 (Social
Services Director) stated that she was asked to see R38 regarding missing credit card. V15 stated that V4
had done some of the investigation so she had V4 also present during meeting with R38. V15 stated that
R38's POA had the credit card. V15 stated that by the time she followed up with R38, the bank had already
reimbursed her. V15 stated that she did not speak with R38's POA to confirm she had R38's credit
card.R38's police report, dated 10/1/2025 at 5:06 PM, notes the police officer spoke with V1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145197
If continuation sheet
Page 3 of 6
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
01/16/2026
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
(Administrator) via telephone. V1 advised that he believed V20 (CNA) assigned to R38's room the day
R38's card had been used at an ATM, was responsible. V1 stated to the police officer that V20 had been
assigned to another resident who had his debit card stolen. V20 had been talking to another staff member
about how he had a scam system going on at the facility. Contact was made with R38's POA, who related
she was aware of the incident, but did not know all the details. Bank statement for R38 was sent to the
police department. R38's POA notified police officer that R38 had received her money back from the
fraudulent transactions, besides the $2.50 fee from the ATM. Abuse prevention and reporting policy, revised
10/24/2022, notes this facility affirms the right of our residents to be free from abuse, neglect, exploitation,
misappropriation of property, deprivation of goods and services by staff or mistreatment. Employees are
required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation,
mistreatment or misappropriation of resident property they observe, hear about, or suspect to the
administrator immediate. The appointed investigator will, at a minimum, attempt to interview the person who
reported the incident, anyone likely to have direct knowledge of the incident and the resident, if
interviewable. Any written statements that have been submitted. Residents to whom the accused has
regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to
determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or
misappropriation of resident property by the accused individual. When an allegation of abuse, exploitation,
neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative
and the Department of Public Health 's regional office shall be informed by telephone or fax. Public Health
shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or
misappropriation of resident property has been reported and is being investigated. The term immediately as
it is used in this policy in relation to reporting misappropriation of resident property, and suspicion of a
crime shall be defined as, following management of the immediate risk to the resident or residents,
including the administration of necessary medical attention, and establishing the safety of the resident or
residents involved or not later than two hours after forming the suspicion. Within five working days after the
report of the occurrence, a complete written report of the conclusion of the investigation, including steps the
facility has taken in response to the allegation, will be sent to the Department of Public Health
Event ID:
Facility ID:
145197
If continuation sheet
Page 4 of 6
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
01/16/2026
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based 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. Findings include:On 1/14/26 at 9:50 AM, R38 stated that R38 was admitted to this facility
August 2025. R38 stated that R38 gave her credit card to V14 (Business Office Manager) for V14 to
process a payment to this facility. R38 stated that V14 returned credit card to R38 and placed card and
receipt on R38's over the bed table. R38 stated that she is bedridden and does not leave her room. R38
stated that later when she went to put credit card back in her zippered pouch, R38 could not find credit
card. R38 stated that she notified V14 that she could not find her card. R38 stated that she does not recall if
she was checking her bank account or if the bank notified her, but there was an alert on her account for
unusual activity. R38 stated that there were two charges, one to a florist for $500.00 and one was cash
withdrawal from a bank for $800.00 plus a $2.50 service fee for transaction. R38 stated that R38 was told to
freeze her card so no further purchases could be made. R38 stated that a couple of days later the police
came to the facility to get her statement; afterwards the police gave her a card with the case number on it.
R38 stated that she informed the police who she thought it could be that took her card. R38 stated that V20
(Certified Nursing Assistant/CNA) was inquiring about how R38 picks her lucky numbers. R38 told V20 that
she chooses birth dates or other occasions. R38 stated that R38's family member has access to R38's
bank account but R38 has the card. R38 stated that the bank did reimburse her for the two charges. R38
stated that she feels unnerved by this event. R38 stated that she has been robbed before in the community,
but to think this could happen in a nursing home in which she should be safe is scary.R38's BIMS (brief
interview of mental status) score, dated 8/8/25, notes R38's score is 15 out of 15. R38 is able to make
needs known.R38's abuse/neglect screening, dated 8/5/25, notes R38 is at moderate risk for abuse.On
1/14/25 at 10:25 AM, V14 (Business Office Manager) stated that when R38 informed her that her credit
card was missing, V14 reported it to V1 (Administrator). V14 stated that the police were notified, and a
report was made. V14 stated that the incident occurred in September 2025. V14 stated that she assumes it
was a staff member because R38 doesn't go anywhere.On 1/14/26 at 10:48am, V1 (Administrator) stated
that V4 (Resident Liaison) would be the person who would know more information regarding R38's missing
credit card. V1 stated that R38's credit card was missing, R38's POA (Power of Attorney) had it. V1 stated
that R38 was concerned about the charges to her bank account. V1 stated that R38 called her bank, there
were two charges not familiar to R38. V1 stated that V4 was on phone with R38 and the bank and knows
more about these charges. V1 stated that the bank reimbursed R38 for the charges. V1 stated that no
reportable was made for this event.On 1/14/26 at 10:53 AM, V4 (Resident Liaison/Staffing Coordinator)
stated that she reported to V15 (Social Services Director) that R38's credit card was missing. V4 stated that
she called R38's bank with R38 on 10/10/25. V4 stated that the bank informed them that the bank would
investigate the pending charges on R38's card and reimburse R38 if the charges were determined to be
fraudulent. V4 stated that she does not know why a reportable was not completed for this event.On 1/14/26
at 11:14 AM, V15 (Social Services Director) stated that she was asked to see R38 regarding missing credit
card. V15 stated that V4 had done some of the investigation so she had V4 also present during meeting
with R38. V15 stated that R38's POA had the credit card. V15 stated that by the time she followed up with
R38, the bank had already reimbursed her. V15 stated that she did not speak with R38's POA to confirm
she had R38's credit card. R38's police report, dated 10/1/2025 at 5:06 PM, notes the police officer spoke
with V1 (Administrator) via telephone. V1 advised that he
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145197
If continuation sheet
Page 5 of 6
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
01/16/2026
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)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
believed V20 (CNA) assigned to R38's room the day R38's card had been used at an ATM, was
responsible. V1 stated to the police officer that V20 had been assigned to another resident who had his
debit card stolen. V20 had been talking to another staff member about how he had a scam system going on
at the facility. Contact was made with R38's POA, who related she was aware of the incident, but did not
know all the details. Bank statement for R38 was sent to the police department. R38's POA notified police
officer that R38 had received her money back from the fraudulent transactions, besides the $2.50 fee from
the ATM. The facility was unable to present any documentation that a investigation was initiated, witness
statements were obtained, R38 interviewed, or alleged perpetrator, V20, was interviewed regarding this
event. Abuse prevention and reporting policy, revised 10/24/2022, notes this facility affirms the right of our
residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods
and services by staff or mistreatment. All incidents will be documented, whether or not abuse, neglect,
exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any
incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident
property will result in an investigation. The appointed investigator will, at a minimum, attempt to interview
the person who reported the incident, anyone likely to have direct knowledge of the incident and the
resident, if interviewable. Any written statements that have been submitted. Residents to whom the accused
has regularly provided care, and employees with whom the accused has regularly worked, will be
interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation,
mistreatment or misappropriation of resident property by the accused individual.
Event ID:
Facility ID:
145197
If continuation sheet
Page 6 of 6