Inspection·April 10, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her to get dialysis and he didn't want her to miss her day anyway. Next thing I know is that I got a call from V5 (dialysis nurse) and they told me that the resident coded and and since she was DNR (Do Not Resuscitate) they didn't do CPR or anything. Surveyor asked whether the charge nurse or doctor was contacted regarding the abnormally low blood pressure, V4 said, I did not, I just followed the doctor's order to give the medication when the blood pressure is low. Surveyor asked what the determining factor or level of hypotension (low blood pressure) that would warrant her to give the medication or inform the doctor, V4 said, There's no particular number but if it's not at baseline blood pressure which was around the upper 110's. Surveyor asked if R2's blood pressure was at baseline, V4 said, No, it wasn't. Surveyor asked if the doctor should have been called in this instance, V4 said, Probably. Review of R2's February MAR (medication administration record) and interdisciplinary progress notes showed that the anti-hypotensive medication Midodrine was not administered/provided on [DATE] as indicated in interview by V4. Furthermore, the last time the medication Midodrine was provided to R2 as shown in the MAR was on [DATE] when the resident previously experienced abnormally low blood pressure. There were no documented entries in R2's record showing V4 informed the RN in charge or physician of the low blood pressure prior to receiving dialysis. On [DATE] at 1:38 PM, V2 (director of nursing ) stated, The nurse should be looking at the MAR (medication Administration Record) to see whether blood pressure medications were given or held prior to going to dialysis. If the blood pressure is too low, we would normally give Midodrine or if it's too high than to give blood pressure medications. The nurse should be assessing for vital signs and fill out the communication form that goes with the patient to dialysis. The nurse should check for code status, the last and current vitals and any medication changes and whether the patient is on isolation. All this should be filled out and given to the dialysis nurse We assess the resident before they are taken up for dialysis treatment and are weighed before and after dialysis. Surveyor asked if the doctor should be informed of any changes in condition such as an abnormally low or high blood pressure, V2 said, It depends on nursing judgement whether to call the doctor or not. On [DATE], a facility-to-dialysis communication report dated [DATE] written by V4 (LPN), reads: 10:22 AM prior to receiving dialysis, R2 's blood pressure was 104/52. (There was no indication or communication noted pertaining to having received anti-hypotensive medications prior to dialysis treatment). Treatment Flowsheet dated [DATE] written by V5 reads in part, Patient Alert and Oriented x1, was confused, per V4 patient was hypotensive on the floor before dialysis. Patients pre-dialysis vitals were 106/65 Pulse 128 with a low resting blood pressure and tachycardia. The Illinois General assembly on Professions, Occupations, and Business Operations (225 ILCS 65/) Nurse Practice Act.(225 ILCS 65/55-30) (Section scheduled to be repealed on [DATE]) Sec. 55-30 reads in part, LPN scope of practice. Practice as a licensed practical nurse means a scope of nursing practice, with or without compensation, under the guidance of a registered professional nurse or an advanced practice registered nurse, or as directed by a physician assistant, physician, or other health care professionals as determined by the Department, and includes, but is not limited to, all of the following: Conducting a focused nursing assessment and contributing to the ongoing comprehensive nursing assessment of the patient performed by the registered professional nurse. Collaborating in the development and modification of the registered professional nurse's or advanced practice registered nurse's comprehensive nursing plan of care for all types of patients. Implementing aspects of the plan of care. Participating in health teaching and counseling to promote, attain, and maintain the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145969 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 145969 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130 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 0658 Level of Harm - Minimal harm or potential for actual harm optimum health level of patients. Serving as an advocate for the patient by communicating and collaborating with other health service personnel. Participating in the evaluation of patient responses to interventions. Communicating and collaborating with other health care professionals. Providing input into the development of policies and procedures to support patient safety. (Source: P.A. 100-513, eff. 1-1-18.) Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145969 If continuation sheet Page 3 of 3