Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to provide for pressure redistribution to prevent a resident's
(R1) pressure injuries from developing out of 3 residents reviewed for pressure ulcers. This failure resulted
in R1 developed avoidable bilateral buttock pressure injuries identified as facility acquired stage three
pressure ulcer (left buttock) and unstageable pressure ulcer (right buttock).
Residents Affected - Few
Findings include:
R1's Face sheet documents that R1 is an [AGE] year-old male who has diagnoses is not limited to:
Parkinson's disease without dyskinesia, dementia, chronic obstructive pulmonary disease, need for
assistance with personal care, weakness.
R1's admission Minimum Data Set (MDS) section M dated 01/29/2024 documents R1 is at risk for pressure
ulcers and documents R1 does not have any pressure ulcers.
R1's admission Minimum Data Set (MDS) section GG dated 01/29/2024 documents R1 needs extensive
assistance for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower,
dressing, and transfers.
R1's MDS/Minimum Data Set Section C dated 04/26/2024 shows R1 has a BIMS/Brief Interview for Mental
Status score of 99, indicating that R1 was unable to complete the interview due to severe cognitive
impairment.
R1's Minimum Data Set (MDS) section M dated 04/26/2024 shows R1 has one stage 2 pressure ulcer and
one unstageable pressure ulcer.
R1's Minimum Data Set (MDS) section GG dated 04/26/2024 documents R1 needs extensive assistance
for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower, dressing, and
transfers.
R1's discharge Minimum Data Set (MDS) section GG dated 05/14/2024 documents R1 needs extensive
assistance for eating and bed mobility, and R1 is dependent on oral hygiene, toileting hygiene, shower,
dressing, and transfers.
R1's discharge Minimum Data Set (MDS) section M dated 05/14/2024 shows R1 has one stage 3 pressure
ulcer and one unstageable pressure ulcer.
R1's doctor's progress note, 04/16/2024 4:35 PM, documents in part: buttocks are healed. left heel
(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 3
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
06/21/2024
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 0686
is better. 0.8 X 1.2 X 0.1 CM
Level of Harm - Actual harm
R1's weekly skin observation note, 04/17/2024 1:31 PM, documents in part: skin concerns observed: Right
buttock - Resolved, Left heel - DTI (deep tissue injury), measures: 0.8 x 1.2 cm. Skin concerns observed
are not new.
Residents Affected - Few
R1's skin note, 04/21/2024 at 07:26 AM, documents in part: R1 was seen, and skin was examined.
Measurements were taken, for the left buttock, 4.0 x 2.0 x 0.1 cm, for the right buttock it measures, 5.0 x
3.0 x 0.1 cm. The resident is currently using a LAL mattress and is currently on treatment for a DTI on his
left heel. Staff were reminded regarding incontinence care and turning of residents. Also, referred to the
Dietician for dietary management of the wound.
R1's doctor's progress note, 04/23/2024 5:25 pm, documents in part: r. (right) buttocks has a black eschar.
5 x 3 x. 0.l (left) heel is larger. 2.5 x 3 cm.
On 6/18/24 at 3:24 PM V4 (Registered Nurse/Treatment nurse) states that he began working as the
treatment nurse in March 2024. V4 states that when there is documentation that a wound is healed, V4
states that it means it is already resolved, and V4 states it means the resident is discharged from wound
care rounds. V4 states it is up to the doctor or NP (nurse practitioner) to determine appearance of a healed
wound, but V4 states that for him, it means the skin is already intact. Surveyor questioned V4 what was the
significance of R1's bilateral buttocks healed and four days later R1's bilateral buttocks noted with the
following measurements (left buttock, 4.0 x 2.0 x 0.1 cm, and right buttock, 5.0 x 3.0 x 0.1 cm) per V4's
documentation? V4 states that for four days, there was a bit of change, and V4 states that maybe the
resident didn't receive wound care, V4 states maybe R1 was not turned as scheduled, maybe the resident's
skin was not checked. V4 states maybe R1 was not eating enough nutrition, V4 states maybe if R1 stayed
too long in bed. V4 states R1 was already being followed by wound care team and the prior wound care
nurse. V4 states that he continued to follow R1 during the course, V4 states that wound care team were
more focused on his sacrum wound and V4 states R1 would stay in the wheelchair per R1's wife request,
so V4 states it was quite difficult to manage the wound.
On 6/18/2024 at 2:10 PM V5 (Director of nursing/DON) states that in general wound preventative measures
include turn and reposition as needed. V5 states that all residents are on weekly skin observations and V5
states that the overnight nurse is responsible to conduct these skin assessments. V5 states since this
building just got acquired, V5 states that staff began the weekly observations in April 2024.
On 6/18/2024 at 3:57 PM, V6 (Doctor of Medicine/Wound Clinician) states that he remembers R1. V6 states
that it is hard to say if R1's wounds could have been preventative, V6 states it can be a contribution of
nutrition and V6 worries that both wounds had deteriorated. V6 states more is going on with nutrition, diet,
and V6 is not sure what the dietitian had for him. V6 states pressure can contribute to it. Surveyor informed
V6 R1 is dependent on care. V6 states that both the heel and buttocks deteriorating can be due to
pressure, nutrition, turn and reposition, and V6 states then the nurses must do more turning. V6 states that
he agrees the wounds could have been prevented from opening to that measurement and appearance
within four days. V6 states that his next note on April 30th, 2024, indicates the heel is larger and left buttock
wound, and right buttock wound is the same measurement as previously.
On 6/21/2024 at 1:13 PM V7 (Certified Nursing Assistant/CNA) states that R1 was a very sweet man to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 2 of 3
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
06/21/2024
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 0686
Level of Harm - Actual harm
Residents Affected - Few
take care of. V7 states that R1 was total care. V7 states that when R1 would be able to be up in the
wheelchair, R1 was able to feed himself. V7 states that when R1 was up in his wheelchair, R1's ability to
feed self was way more successful than in bed. V7 stated for example, in the morning, because we didn't
get him up until mid-morning, for lunch he was a feeder for only 10% of the time. For breakfast he was a
feeder, like 90%. We would still sit with him and encourage him and open items up. We were still with him.
V7 states that for the last week to a month R1 was in the facility, R1 wasn't eating as well. V7 states that
she is the wound care assistant and was able to see his wounds once a week during wound care rounds.
V7 states it was one moment of him sitting too long and it could have opened again. V7 states that R1 could
not be sitting up in his wheelchair no longer than 3 hours. V7 states if R1 got up at 11am, V7 states R1 had
to be back in bed by 1pm. V7 states staff would give report to each other, CNAs to CNAs. V7 states some
people would say they had the hardest time with R1, and I just couldn't get him to turn over. V7 states these
statements were from the newer CNAs.
On 6/21/2024 at 3:00 PM V8 (Director Regional Dietitian Consultant) states that V8 conducted an
assessment for R1 on May 8th, 2024, and on March 8th, 2024. V8 states that another dietitian conducted
R1's assessment in April 2024. V8 states that R1 had a weight loss. V8 states there was intake
improvement in May. V8 states that March intake was fair. V8 states that they base it on the nursing
assistants' documentation and what they charted for residents' intake. V8 states if the CNAs charted that
the resident ate ten times good and three times poor then it is fair intake. V8 states it depends on the
individualized dietitian's clinical judgment.
R1's wound assessment detail report dated 5/14/2024 documents in part, right buttock active, typepressure ulceration, source- facility acquired, unstageable.
R1's wound assessment detail report dated 5/14/2024 documents in part, left buttock active, type- pressure
ulceration, source- facility acquired, stage three.
R1's care plan dated 1/24/2024 documents in part: the resident will be free from injury through the review
date.
R1's physician order set documents in part: House Nutrition Supplement three times a day for nutrition
support give 120ml TID (three times a day), Nutritional Treat one time a day - one cup of Yogurt (Family
supplied), protein Sugar Free supplement one time a day 30 ml, nutritional shake two times a day
supplement.
R1's weight log documents the following: 01/23/2024 - 196.6 lbs (pounds), 1/28/2024- 195 lbs, 2/06/2024196 lbs, 03/01/2024- 196.3 lbs, 4/11/2024- 176.2 lbs, 04/30/2024- 176.2 lbs, 05/04/2024- 169.2 lbs. R1's
weight documents R1's weight remained the same during the period R1's bilateral buttocks healed and
R1's bilateral buttock wounds were noted.
The facility's Policy, titled Skin Condition Assessment & Monitoring- Pressure and Non-Pressure dated
6-8-18, documents in part, the resident's care plan will be revised as appropriate, to reflect alteration of skin
integrity, approaches and goals for care.
The facility's Policy, titled Pressure Ulcer Prevention dated 1/15/2018, documents in part, to prevent and
treat pressure sores/pressure injury, turn dependent resident approximately every two hours or as needed,
wheelchair residents may be instructed to shift weight from one buttock to the other.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145591
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the June 21, 2024 survey of APERION CARE WESLEY?
This was a inspection survey of APERION CARE WESLEY on June 21, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at APERION CARE WESLEY on June 21, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.