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Inspection visit

Health inspection

APERION CARE OAK LAWNCMS #1451973 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

3 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

FAQ · About this visit

Common questions about this visit

What happened during the January 16, 2026 survey of APERION CARE OAK LAWN?

This was a inspection survey of APERION CARE OAK LAWN on January 16, 2026. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at APERION CARE OAK LAWN on January 16, 2026?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.