Inspection·May 27, 2025

F 0675 Honor each resident's preferences, choices, values and beliefs. 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 a resident's comfort by failing to provide a comfortable mattress resulting in R1 lying in a sunken mattress. This failure affect one of three residents (R1) reviewed for comfortable mattresses. Residents Affected - Few Finding includes: R1 was observed lying on bed. R1 mattress observed sunk in. Surveyor observed 3 fans in R1's room. One fan was broken, another fan provided by the facility but not the same kind as the broken fan, the 3rd fan is the same kind as the broken fan. R1 said that his family bought him the fan and he will like the facility to refund the money. R1 is oriented and can make his needs known. R1 said that he told V3 (Maintenance Director) about his mattress not being good. R1 said that V3 said that V3 will replace it but it has not been replaced yet. R1 said that R1 told V4, Licensed Practical Nurse (LPN) about his mattress and V4 wrote it up. On 5/27/2025 at 12:30 PM, V3 (Maintenance Director) said that R1 called V3 either on Thursday or Friday last week and told V3 that something was wrong with his mattress. V3 said that V3 examined the mattress and saw that the mattress is deflated on one side. V3 said that V3 told R1 that R1 mattress will be replaced. On 5/27/2025 at 12:35 PM, V1 (Administrator), V3, and surveyor went to R1 room. V3 asked R1 when he will be out of bed so that his mattress can be replaced. R1 said that he will be ready after lunch for the Certified Nursing Assistant (CNA) to get him out of bed. On 5/27/2025 at 1:06 PM, V4 (LPN) said that R1 told V4, LPN last week that something is wrong about his mattress. V4 said that R1 said that he has been telling them and waiting for something to be done about his mattress. V4 said that R1 did not mention to V4 who R1 notified about his mattress. V4 said that R1 is oriented and takes care of his business. V4 said that she did not report it or document it in the maintenance log because R1 said that R1 reported it and just waiting for it to be replaced. On 5/27/2025 at 1:30 PM, V2 (Director of Nursing) said that she was not aware of R1 mattress. V2 said that she expects staff to write resident's complaints about furniture and equipment in the facility work order. V2 said that Maintenance comes in and check work order daily. On 5/27/2025 at V1 (Administrator)said that if a concern is told directly to a maintenance supervisor, V1 does not expect it to be in the maintenance logbook. V1 said that V1 expects the resident's need to be met as soon as possible and that depend on situation. (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 2 Event ID: 145969 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 05/27/2025 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)