Inspection visit
Inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
Based on observations, interviews, and record reviews, the facility failed to provide an accurate
person-centered care plan for ADL (Activities of Daily Living) related to transfers for 2 out of 19 residents
reviewed for accuracy of care plan. This failure has the potential for facility staff to follow incorrect care plan
interventions related to transfers.
Findings include:
On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing
Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the
resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped
working. V10 went to the door with her head outside of the door looking side to side for staff but was not
able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took
the remote control of the lift, but no matter how many times V10 pushed the button to make R63 move
down, the lift does not respond. Writer then went to the Nurse's Station and informed V11 (Registered
Nurse) that there was a resident hanging on the lift inside the shower room. V11 nodded but did not go to
the shower room. V12 (Restorative Aide) finally went to the shower room. Again, V11 was informed by
writer. V11 said, I did not come because I thought V12 was already responding to you. Now with V11, V12
and V10 in the shower room, V12 manually maneuvered to take off both arms of R63 who was expressing
pain. V12 then said, The lift is plugged, once it is plugged it will be in a charging mode and will not perform.
It only works when it is in a battery mode and unplugged. V12 said, When transferring a resident with a lift,
any kind of lift, it must be performed by at least 2 persons. V12 was informed that R11 was seen earlier with
V13 (Certified Nursing Assistant) about to transfer R11 with Hoyer lift.; and that no other staff was present
except V13. V12 said, Sometimes staff will prepare a resident for transferring and call for help when
resident is ready to be transferred. V12 was then requested to go to R11's room to check if R11 was being
safely transferred by V13 with another staff assisting.
On 03/14/2023 at 11:33 AM, upon entering the room, R11 was already transferred by V13 (Certified
Nursing Assistant) with Hoyer lift without any other staff present. V12 said, Again, as I said earlier. All lifts
must be performed for transferring a resident with at least 2 persons. V13 said, I transferred R11 by myself
because all other CNAs (Certified Nursing Assistant) are busy doing other residents. But I agree, safety of
the resident is more important than doing my job fast. Next time I will wait for help.
On 03/16/2023 at 11:20 AM, V16 (MDS Coordinator/Restorative Supervisor) said, Yes, there is an
inconsistency with both R63 and R11's care plans on ADLs (Activity of Daily Living) specific to transfers. It
should be documented as 2 persons assist because MDS assessment under functional status coded
(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 10
Event ID:
145591
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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
2-person extensive assist on transfer. Fall care plan is correct because it documents 2-person assist during
transfer. R63 and R11 both need full assistance during transfers. This may be caused by change of
electronic health record system; but I can manually change interventions in the care plan. Both (R63 and
R11) are using lifts. When using mechanical lift like sit-to-stand or Hoyer lifts there must be 2 persons doing
the transfer. One person maneuvering the resident, and the other person operating the lift. The reason is for
safety of resident to avoid or prevent fall.
On 03/16/2023 at 01:23 PM. V18 (Rehab Manager / Physical Therapist) said, Yes, any mechanical lift use
must be performed by 2 persons. R63 declined and on bed bound status, same as R11. We do not transfer
residents, it is the nurses who does transferring.
Fall Care Plans: Both R63 and R11's plan of care on fall intervention, read in part that during transfer using
lift there must be 2-persons performing the transfers. ADL (Activity for Daily Living) on transfer under
interventions, in part reads: Transfer with 1 person assist.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 2 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 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.
Based on observations, interviews, and record reviews, the facility failed to follow their safety protocols on
transfers of 2 out of 4 residents (R63 and R11) of the the total sample of 19 residents reviewed for hazard
and accidents transferring 2 residents with mechanical lifts (sit-to-stand and Hoyer) with only 1 person
performing the transfers. These failures have resulted in 1 resident (R63) hanging suspended on the
sit-to-stand lift complaining of pain; and another resident (R11) having the potential for fall.
Findings include:
On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing
Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the
resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped
working. V10 went to the door with her head outside of the door looking side to side for staff but was not
able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took
the remote control of the lift, but no matter how many times V10 pushed the button to make R63 down, the
lift does not respond. Writer then went to the Nurse's Station and informed V11 (Registered Nurse) that
there was a resident hanging on the lift inside the shower room. V11 nodded but did not go to the shower
room. V12 (Restorative Aide) finally went to the shower room. Again, V11 was informed by writer. V11 said,
I did not come because I thought V12 was already responding to you. Now with V11, V12 and V10 in the
shower room, V12 manually maneuvered to take off both arms of R63 who was expressing pain. V12 then
said, The lift is plugged, once it is plugged it will be in a charging mode and will not perform. It only works
when it is in a battery mode and unplugged. V12 said, When transferring a resident with a lift, any kind of lift
it, must be performed by at least 2 persons. V12 was informed that R11 was seen earlier with V13 (Certified
Nursing Assistant) about to transfer R11 with Hoyer lift; and that no other staff was present except V13. V12
said, Sometimes staff will prepare resident for transferring and call for help when resident is ready to be
transferred. V12 was then requested to go to R11's room to check if R11 was being safely transferred by
V13 with another staff assisting.
On 03/14/2023 at 11:33 AM, upon entering the room, R11 was already transferred by V13 (Certified
Nursing Assistant) with Hoyer lift without any staff present. V12 said, Again, as I said earlier, all lifts must be
performed for transferring resident with at least 2 persons. V13 said, I transferred R11 by myself because all
other CNAs (Certified Nursing Assistant) are busy doing other residents. But I agree, safety of the resident
is more important that doing my job fast. Next time I will wait for help.
On 03/15/2023 at 02:56 PM. V2 (Director of Nursing) said, Best practice when using mechanical lift in
transferring resident; whether Sit to Stand or Hoyer lifts must be 2 or more persons. That is for the safety of
the resident. It depends on the situation, personal opinion, 2-person should be the correct way to transfer
resident with a lift. After submitting the policy for Safe Lifting and Movement of Residents, V2 said, Yes, it
does not show that at least 2 persons needs to be during transfers with equipment. But it's in an old policy
and we will review, and are in the process of modifying the policy that I will provide to you soon.
On 03/16/2023 at 11:20 AM. V16 (MDS Coordinator / Restorative Supervisor) said, When using mechanical
lifts like sit-to-stand or Hoyer lifts there must be 2 persons doing the transfer. One person
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 3 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
maneuvering the resident, and the other person operating the lift. The reason is for safety of resident to
avoid or prevent fall.
On 03/16/2023 at 01:23 PM. V18 (Rehab Manager / Physical Therapist) said, Yes, any mechanical lift use
must be performed by 2 persons. R63 declined and on bed bound status, same as R11. We do not transfer
residents, it is the nurses who does transferring.
Fall Care Plans: Both R63 and R11's plan of care on fall intervention, read in part that during transfer using
lift there must be 2-persons performing the transfers.
Safe Lifting and Movement of Residents Policy dated as updated 03/2023, in part reads: To protect the
safety and well-being of staff and residents, and to promote quality of care, this uses appropriate
techniques and devices to lift and move residents. Under Use of Mechanical Lifting Devices, mechanical
lifting devices such as Hoyer lift or Sit to Stand Device shall be used for heavy lifting, including lifting, and
moving residents, when necessary, Check battery if fully charged before using it. There must be at least 2
persons when using lifts
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 4 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and record review, the facility failed to follow their policy to account for the
correct number of narcotics in the residents individual controlled substance record for 1 (R67) out of 3
residents reviewed for pharmaceutical services in a sample of 19.
Findings include:
On 03/15/23 at 11:38 AM, surveyor counted narcotics with V11 (Registered Nurse) on the 3rd floor
medication cart. While counting with V11, R67's Lorazepam every 4 hours as needed pill box has 14 pills
and 32 pills in R67's Lorazepam every 6 hours scheduled pill box.
On 03/15/2023 at 11:39 AM, surveyor reviewed the Individual control substance record for R67's
Lorazepam with V11.
R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4 PRN (every 4 hours as
needed) documents in part: 2/16 amount remaining 19. 2/17 amount remaining 18 with no nurse's
signature. 2/18 amount remaining 1 with V11's signature.
R67's Narcotics Individual Controlled Substance Record for Lorazepam scheduled Q6 (every 6 hours)
documents in part: 3/15 amount remaining 30 pills remaining.
On 03/14/2023 at 11:40 AM, V11 (Registered Nurse) stated that he (V11) will figure out what happened to
the medications.
On 03/15/2023 at 12:00 PM, V11 stated, What might have happened is that, when they gave the scheduled
every 6 hours Lorazepam, the nurse might have given the lorazepam from the every 4 hours as needed pill
box and not the scheduled. So, I (V11) moved two pills from R67's every 6 hours scheduled lorazepam pill
box to R67's every 4 hours as needed pill box making the count 16. The nurse who gave the medication to
R67 was V33 (Registered Nurse)
On 03/15/2023 at 12:02 PM, surveyor again reviewed R67's Narcotics Individual Controlled Substance
Record for Lorazepam PRN Q4 with V11. R67's Narcotics Individual Controlled Substance Record for
Lorazepam PRN Q4 this time documents in part: 2/17, 12 PM, 0.5 pill given, V33's signature, remaining
count 18. 3/13, amount given: wasted, amount remaining: 16.
On 03/15/2023 at 12:03 PM, surveyor asked V11, How did this signature get here when it wasn't there
before?
V11 responded, I (V11) went downstairs and have V33 sign R67's Narcotics Individual Controlled
Substance Record for Lorazepam PRN Q4. V11 stated the nurse should sign the Narcotics Individual
Controlled Substance Record the moment the medication is administered and not back dating. V11 also
stated that he (V11) did not accurately document administration when he (V11) gave the Lorazepam on the
2/18.
On 03/15/2023 at 12:05 PM, surveyor asked V11, Don't you do narcotic count in the morning at the start of
your shift? V11 stated, I (V11) do but I did not count accurately and catch this discrepancy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 5 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0755
Level of Harm - Minimal harm
or potential for actual harm
On 03/15/2023 AT 2:24 PM V2 (Director of Nursing) stated, I (V2) expect them to do the narcotic count at
the beginning of the shift and at the end. Every time they give a narcotic, the nurse who administered it,
needs to sign it out. If they do not give a medication, they should not sign it. Narcotics in the fridge such as
morphine should be double locked. If it has a potential for somebody to break in the refrigerator and remove
and abuse the medication. V2 stated, No one mentioned to me (V2) about any narcotic discrepancy.
Residents Affected - Few
On 03/16/2023 at 11:00 AM, V33 (Registered Nurse) stated that she (V33) was the nurse who gave R67
her (R67) medication. V33 stated she (V33) did not sign the R67's MAR and forgot to sign R67's Narcotics
Individual Controlled Substance Record for the scheduled every 6 hours Lorazepam, the day she (V33)
gave R67 the Lorazepam.
On 03/16/2023 at 12:00 PM, V3 (Assistant Director of Nursing/Infection Preventionist) stated that the
correct and expected documentation of medication administration is that only the nurse who administers
the medication should sign off on the MAR and the Narcotics Individual Controlled Substance Record.
R67's Medication Administration Record for 02/2023 documents in part: Lorazepam Oral Tablet 0.5 MG
(Lorazepam) Give 1 tablet by mouth every 6 hours, 2/17/2023, 1 pill administered by V11.
Facility's Documentation of Medication Administration policy (1/2017) documents in part: Administration of
medication must be documented immediately after it is given. Documentation must include as a minimum:
Signature and title of the person administering the medication, date and time of administration.
Facility's Controlled Substances policy (8/2021) documents in part: An individual resident-controlled
substance record must be made for each resident who will be receiving a controlled substance. This record
must contain signature of nurse administering medication. Nursing staff must count controlled medications
at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count
together. They must document and report any discrepancies to the Director of Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 6 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to follow their policy to ensure the
narcotics in the refrigerator are stored in a separate locked container separate from any non-controlled
medications for 2 medication refrigerators reviewed for medication storage and labeling.
Findings include:
On 03/15/2023 at 12:25 PM, surveyor observed and reviewed the 4th floor refrigerator with medications.
Surveyor observed the medication refrigerator is in the nurse's station where the nurse sits to document.
There is no locked door to go into the nurse's station. Surveyor found liquid lorazepam, and liquid morphine,
not in a separate lock box, and with all other medications such as insulin. There was an empty separate
brown lock box was broken and not locking.
On 03/15/2023 at 12:27 PM, V34 (Registered Nurse) stated that he (V34) is the nurse for all of the 4th floor.
V34 stated there is no separate locked medication room. V34 stated the refrigerator is next to them where
the nurse sits in the nurse's station. V34 stated the narcotics should be behind a double lock separate from
all other non-controlled medications. V34 stated this is important so no one removes and abuses the
narcotics.
On 03/16/2023 at 10:07 AM, surveyor observed and reviewed the 3rd floor refrigerator with medications.
Surveyor observed the refrigerator is in the nurse's station where the nurse sits to document. There is no
locked door to go into the nurse's station. Surveyor found liquid lorazepam, and liquid morphine, not in a
separate lock box, and with all other medications such as insulin.
On 03/16/2023 at 10:08 AM, V11 stated he (V11) is the nurse for all of the residents on the 3rd floor. V11
stated there is no separate locked medication room. V11 stated the narcotics should be behind a double
lock separate from all other non-controlled medications.
On 03/15/2023 AT 2:24 PM V2 (Director of Nursing) stated, Narcotics in the fridge such as morphine should
be double locked; if it has a potential for somebody to break in the refrigerator and remove and abuse the
medication.
Facility's controlled substance policy (8/2021) documents in part: Controlled substances must be stored in
the medication room in a locked container, separate from containers for any non-controlled medications.
This container must remain locked at all times, except when it is accessed to obtain medications for
residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 7 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of
expired food products and failed to ensure the kitchen was free from potential contamination. These failures
have the potential to effect 71 residents that take food by mouth of 72 residents residing in the facility.
Findings include:
On 3/14/23, Surveyor observed an opened bag of frozen french fries in a freezer with a manufacturer
expiration date of 8/4/22 and an opened date of 1/29/23 written on the bag by staff.
On 3/14/23, Surveyor observed 4 containers of basil pesto in a freezer with manufacturer best by date of
1/7/23.
On 3/14/23, Surveyor observed 6 plastic containers of jellied cranberry sauce in the dry storage area with
manufacturer expiration date of 5/8/21.
On 3/14/23 at 10:15 AM, V35 (Dining Service Director) stated Staff should check the expiration dates
before opening items.
On 3/14/23, Surveyor observed V37 (Field Tech with pest control) enter the kitchen dishwasher area with
mask worn below the chin, not covering mouth or nose, and wearing a winter skull hat. V37 was talking on
the telephone. V37 was not wearing gloves or a hairnet. V37 opened a pest control box located under the
dishwasher countertop area. V37 then leaned over cleaned silverware while continuing to talk on the
telephone with mask worn below the chin, not covering mouth or nose.
On 3/14/23 at 10:30 AM, V37 stated that V37 checked in at the front desk, not with anyone in the kitchen.
V37 stated that V37 was not instructed to wash hands. V37 stated that V37 did not wash hands when V37
entered the kitchen area.
On 3/14/23 at 10:35 AM, V35 (Dining Service Director) stated that V37 should have checked in with kitchen
staff, should have had a mask on correctly and should have washed hands. V35 stated that by not doing
that, there is a possibility for contamination in the kitchen.
On 3/16/23 at 10:45 AM, V36 (Cook) stated We can't have expired foods. Spoiled food can harm the
residents. They could get food poisoning. A lot of residents have low immune systems and if they are
served spoiled food, they can get more sick. Kitchen staff and anyone else in the kitchen should wear a
mask, hairnet, and wash hands so they don't bring in contamination. If the kitchen and food is
contaminated, residents can get sick.
Facility policy Labeling and Dating Foods, 2010, reads in part: A manufacturer's expiration date will be
honored first. Potentially hazardous foods that contain a Sell by date, such as cottage cheese, milk, soft
cheeses, non-cured deli-meats will be labeled with the date it is opened and a use by date which is either
the 6th day it is opened or the Sell by date, whichever is sooner. Commercially processed foods that have
been prepared and packaged by a food processing plant will be labeled with the date it is opened. This will
be discarded either on the 6th day or the Best Used By date.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 8 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Facility policy Hand Washing, 2010, reads in part: Dietary employees will practice safe food handling to
prevent foodborne illness. Dietary employees will thoroughly wash their hands and exposed areas of their
arms with soap and water at the following times: 1. Upon entering the kitchen at the beginning of the shift.
Facility policy Hair Restraints/Jewelry/Nail Polish, 2010, reads in part: Hairnets will be worn at all times in
the kitchen. [NAME] guards or masks will be worn as indicated if needed.
Facility policy Personal Protective Equipment - Using Face Masks - Level 1, last reviewed 8/2021, reads in
part: Purpose To guide the use of masks. Objectives 1. To prevent transmission of infectious agents through
the air.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 9 of 10
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
145591
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aperion Care Wesley
1415 West Foster Avenue
Chicago, IL 60640
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 0888
Ensure staff are vaccinated for COVID-19
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interviews, and record reviews, the facility failed to follow the Covid-19 Vaccine
Policy for Staff by not including in the Staff Matrix multiple Certified Nursing Assistants vaccination status
working through agency agreement performing direct care to residents. These failures have the potential to
affect 72 residents living in the facility in preventing the risk of Covid-19 infections.
Residents Affected - Many
Findings include:
On 03/15/2023 at 11:58 AM, V3 (Infection Preventionist / Assistant Director of Nursing) submitted a Matrix
for staff vaccination status. V3 was asked if all staff performing direct care to residents are included on the
Matrix? V3 said, Yes, all staff are included. Therapist that are working with residents are on the last part.
Upon full review of the Matrix there was no Nursing Staff that was working directly with the residents listed
on the Matrix. V3 was asked about the lack of nursing staff from the agency working on the floor? And that
on 03/14/2023 V10 (Certified Nursing Assistant / Agency) was seen working direct care to residents. V13
said, Oh, I missed it. I will make sure for future monitoring to include all agency staff working direct care
with residents to be included on the Matrix. Facility had an outbreak last January this year (2023), but I
don't think it was related to agency nursing staff performing direct care not being monitored.
Under the Matrix of Facility there are 161 staff (including employed and agency therapist staff). Two (2)
staffs have exemption, which resulted to 98.75%. Matrix did not include Certified Nursing Assistants (CNA)
that agency was providing. On the schedule that facility provided (3/12/2023 to 3/18/2023) there were
multiple CNAs from the agency working on all floors and all shifts performing direct care V10, V18, V19,
V20, V21, V22, V23, V24, V25, V26, V27, V28, V29, V30, and V31. Facility also submitted a list of Covid-19
Positive for both residents and staff for the month of January 2023 with 16 persons (residents and staffs)
combined.
Covid-19 Vaccine Policy of facility dated 01/2023 as updated, in part reads:
It is the policy of the facility that all (100%) facility staff, regardless of clinical responsibility or resident
contact must receive the first dose of a two-dose Covid-19 vaccine or one-dose Covid-19 vaccine prior to
providing any care, treatment, or other facility services. All staff who are fully vaccinated are recommended
to receive a Covid-19 booster.
Facility Staff and Staff refers to individual who provide any care, treatment, or other services for the facility
and/or residents, employees including:
Individuals who provided care, treatment, or other services for the facility and/or its residents, under
contract or by other arrangement.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
20 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0888GeneralS&S Fpotential for harm
Ensure staff are vaccinated for COVID-19
- 0133GeneralS&S Dpotential for harm
Install a two-hour-resistant firewall separation.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 17, 2023 survey of APERION CARE WESLEY?
This was a inspection survey of APERION CARE WESLEY on March 17, 2023. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at APERION CARE WESLEY on March 17, 2023?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
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.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.