Inspection·May 3, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to maintain resident rooms in a clean and sanitary manner for 4 residents R1, R2, R4, R6 reviewed for clean, comfortable, homelike environment in the sample of 21. The findings include: The Facility Data Sheet dated 5/3/24 showed a resident census of 104 residents. On 5/3/24 at 7:40 AM, R2 was seated in bed. A urinal, filled with 600 milliliters (mls) of urine, was on his beside table. No lid was noted on the urinal bottle. Directly next to the urinal, was a sandwich. R2 pointed at the sandwich next to the urinal, I won't eat that. That's terrible. Gross. R2's garbage container, on the floor next to his bed, was overflowing with garbage. On 5/3/24 at 8:00 AM, this surveyor walked down the 200 unit hallway with V3 Certified Nursing Assistant (CNA). This surveyor's shoes stuck to the floor walking down the hallway. V3 wore shoe coverings over her shoes. V3 stated she wore shoe coverings over shoes because I don't like my shoes sticking to the floor either. On 5/3/24 at 8:02 AM, R6 laid in bed. A urinal, half-filled with urine, was noted directly next to R6's glass of drinking water. No lid was noted on the urinal. On 5/3/24 at 8:20 AM, R1 was seated on his bed. R4 was asleep in the bed next to R1. A pungent, foul odor was noted in R1 and R4's room. R1's black bed sheet was soiled with food debris. [NAME] sticky, food debris was noted on R1's floor, around his bed. Cookie wrappers, tissues, and an empty potato chip bag laid on R1's floor. The garbage container next to R1's bed was overflowing. R1 stated, My room is filthy. R4 laid in bed. No sheet was noted on R4's bed. Stool was noted leaking out of R4's incontinence brief, directly onto R4's bare mattress. A facility concern form dated 1/24/24 showed a resident request for his room to be swept. A concern form dated 2/14/24 showed a request for a resident's furniture to be cleaned. A form dated 4/10/24 showed a complaint related to food leftovers being left all over the bed and on the rails. The facility's 4/29/24 Resident Council Minutes showed concerns related to sticky floors and dirty dining rooms were identified. On 5/3/24 at 11:47 AM, V7 Housekeeping Supervisor stated each resident room is to be cleaned, daily, which included emptying garbage, sweeping and mopping floors, wiping down furniture, and cleaning (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 4 Event ID: 145660 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 145660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154 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)