Health inspection·February 21, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify a residents Power of Attorney for healthcare (POAH) of a fall with injury that required Emergency treatment for 1 of 3 residents (R1) reviewed for notification of change in the sample of 5. The findings include: On 2/21/25 at 9:03 AM, V7 (R1's POAH) said she was not informed of R1's fall with injury on 1/8/25 and transport to the hospital. V7 said it was days after the incident that she found out about his Dad's fall (R1) R1 was sent to the ER then sent back to the facility with an Ortho referral. V7 said she did not change her phone number, it was always working and it's the same phone number since R1 got admitted to the facility. V7 also said she works with the Chicago Police Department and there were other ways to get a hold of her. R1's change of condition eval/progress notes dated 1/8/25 by V17 (License Practical Nurse-LPN) documents, (R1) had an unwitnessed fall in his room trying to go to the bathroom by himself. R1 complained of left shoulder pain. R1 had an X-ray STAT (immediate) that show R1 had a left humeral fracture (upper arm bone fracture). R1 was sent to the ER and was sent back to the facility the same day with a sling. Writer attempted to call POA but phone number is not in service. R1's fall incident report under-Family responsible party notified: R1 (the resident), (instead of R1's POAH -V7). On 2/21/25 at 1:12 PM, V12 (Regional Nurse) said resident's family should be notified when a resident had a fall with injury. If unable to get hold through their phone, and if an email was available, then we notify them through email. We can also send a mail that says to call the facility. On 2/21/25 at 2:45 PM, V2 (Director of Nursing) said multiple attempts should be made when notifying family regarding residents change of condition, (fall, transport to the hospital). V2 confirmed that V17 (LPN) was not able to get hold of V7 (R1'S POAH) last 1/8/25. R1's medical record did not show any other attempts of notifying R1's POA after 1/8/25. The facility policy entitled Physician-Family Notification -Change in Condition with revision date of 11/13/18 documents, To ensure that medical care problems are communicated to the physician or authorized designee and family/responsible party in a timely, efficient and effective manner. A.) An accident involving the resident which results in injury and has the potential for requiring physician intervention. Page 1 of 3 145969 145969 02/21/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure treatment orders were initiated for a resident with a stage 2 sacral pressure ulcer. This applies to 1 of 3 (R3) residents reviewed for pressure ulcers in the sample of 5. Residents Affected - Few The findings include: R3's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE]. R3's diagnoses including pressure ulcer of sacral region stage 2, chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis of right lower extremity, and morbid obesity. On 2/21/25 at 10:23 AM, R3 was observed lying in her bed. V8 (Registered Nurse-RN) and V9 (Certified Nursing Assistant-CNA) provided incontinence care to R3. A protective dressing was in place to R3's sacrum. V9 said R3 has a pressure ulcer to her sacrum and is dependent on staff for cares. On 2/21/25 at 10:42 AM, V10 (Wound Nurse) said R3 was admitted to the facility with several wounds. She has a stage 2 pressure ulcer to her sacrum. On admission a skin assessment is performed, and treatment orders should be obtained if the resident has wounds. The treatment orders should be transcribed and you should document when the dressing is changed. R3's Wound Assessment Report dated 2/15/25 shows a stage 2 pressure ulcer present on admission measuring 5.0 cm (centimeters) x 7.0 cm x 0.20 cm. The report does include the treatment orders. R3's Treatment Administration Record (T.A.R.) shows order date 2/18/25 (4 days after admission); sacrum clean with wound cleaner, pat dry with gauze and cover with hyrocolloid dressing every Tuesday, Thursday and Saturday. The facility's Skin Condition Assessment & Monitoring -Pressure and Non-Pressure Policy revised 2018 states, To establish guidelines for assessing, monitoring, and documenting the prescience of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented .physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration . 145969 Page 2 of 3 145969 02/21/2025 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the facility failed to ensure a resident was free from significant medication errors by failing to ensure admission medications were transcribed and administered for 1 of 3 residents (R3) reviewed for medications in the sample of 5. Residents Affected - Few The findings include: R3's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE]. R3's diagnoses including pressure ulcer of sacral region stage 2, chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis of right lower extremity, and morbid obesity. On 2/21/25 at 1:50 PM, V2 (DON) said she was informed on 2/15/25, R3's admission was not done by nursing. She received a call from V15 (Licensed Practical Nurse) that the day shift was nurse upset. V15 reported V16 (LPN) the night shift nurse did not perform R3's admission assessment and orders. V15 said she was not going to do R3's admission and left the facility. V2 said V16 reported she was inexperienced and did not know how to admit a resident. V2 said there was a delay in entering R3's admission orders and confirmed R3's morning and afternoon medications were not administered. V2 said V15 and V16 were terminated after this incident. Staff should admit the resident during their shift, the admission process includes entering the admission orders and medications. R3's Hospital Discharge Summary report dated 2/14/25 shows medications that includes amlodipine 10 mg (milligrams) daily, baclofen 10 mg twice a day as needed for pain, cetirizine 10 mg daily, colace 100 mg daily, duloxetine 20 mg daily, famotidine 20 mg daily, fluticasone inhaler 110MCG (micrograms) inhale 3 puffs twice a day, isosorbide dinitrate 10 mg take one tablet three times a day with meals, lipitor 40 mg daily, carvedilol 12.5 mg every twelve hours, furosemide 40 mg daily, heparin 5000 Unit/ML injectable, inject 1.5 ML every 8 hours, hydralazine 25 MG every 8 hours three times a day for hypertension and insulin lispro inject 8 units before meals for diabetes. R3's Medication Administration Record dated February 2025 shows she was not administered her daily medications on 2/15/25 including Amlodipine 10 mg (milligrams) daily for hypertension, Furosemide 40 mg daily for excess fluid, Cetirizine 10 mg daily for allergies, duloxetine 20 mg daily for depression. R3's M.A.R. for February 2025 shows on 2/15/25, R3 was not administered her morning and afternoon dose for the following mediations: Carvedilol 12.5 mg every 12 hours for hypertension, famotidine 20 mg twice a day for GERD, Fluticasone Inhaler Aerosol 110 MCG/ACT inhale 3 puffs twice a day for COPD, Heparin Injection Solution 5000 units/ML (milliters), inject 1.5 ml three times a day for DVT prophylaxis, hydralazine 25 mg three times a day Insulin Lispro inject 8 units subcutaneously before meals three times a day (all three doses missed on 2/15/25). The facility's Transcription of Physician Orders Procedure dated 2022 states, Transcription of physician order: carefully, review transfer record and discharge summary from the hospital or the transfer record from another health facility, the licensed nurse should notify the physician of the resident's admission, clinical condition and findings, review and clarify transfer orders . 145969 Page 3 of 3