Health inspection·August 14, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few front of the wheelchair after R1 hollered, ow, my leg, R1's leg was under the wheelchair, but she did not know how far it had gone under. In a progress note from 07/29/2025 at 6:28 PM, V13 (RN) stated in part that R1 verbalized pain on her right knee and said that it was during transfer when she went down to the salon this morning. In a progress note from 07/30/2025 at 9:00 AM, V14 (APN) stated in part that R1 presented with very bad knee pain and ten out of ten severity for one to two days. In a progress note from 08/01/2025 at 11:34 AM, V15 (NP) stated in part that R1 complained of pain to her right leg, which was not improving with medication, and the pain had been there since her foot dragged under the wheelchair while she was going for an appointment. On 08/12/2025 at 12:32 PM, V6 (APN, Orthopedic Surgery) told one of the Surveyors that she remembered R1 and her injury while at the hospital; and she believed it would have been unlikely that R1's right foot would have gotten caught underneath the wheelchair if the footrests and her feet were put on properly (if they were put on at all). On 08/12/2025 at 12:40 PM, V5 (Restorative Nurse) told this Surveyor that she assessed residents to determine if they were able to move on wheelchairs unassisted, and in R1's case, she was unable to wheel herself, independently, and needed substantial dependent assistance with locomotion. V5 said she had approved two footrests for R1's wheelchair and had instructed nurses and CNA's to ensure they were attached to R1's wheelchair whenever she was going to any destination. V5 said R1 had minimal strength in her legs, her core strength was weak, she was unable to hold her legs up for a long period of time, and believed that it would always be a safe measure to put both footrests on her wheelchair for long distances, like going to the hair salon. V5 said that due to R1's poor functional abilities in her lower extremities, if she was not positioned well while the CNA was transporting her, there could be a problem; so, the staff should make sure that there was proper resident positioning prior to pushing R1. V5 reiterated that, due to R1's weak lower extremities, it was most important that her feet and body be positioned properly. R1's MDS, section GG, dated 07/18/2025, stated in part that R1 was wheelchair dependent, and, thus, unable to wheel herself fifty feet unassisted. On 08/12/2025 at 2:38 PM, V1 (Administrator) told this Surveyor that the administration did not have a facility policy that addressed the proper supervision and use of wheelchairs on 07/29/2025, when R1's right leg injury happened. V1 said they looked for one but could not find it. V1 also said that no video footage of R1's wheelchair incident on 07/29/2025 existed because it had been erased after seven days, and no one reviewed the footage while it was available because there was a lot of footage to go over in order to locate it. R1's x-ray report, dated 08/01/2025, stated in part that R1 suffered an acute comminuted distal femur fracture and an 11mm lateral displacement with distal fragments. A hospital progress note dated 08/06/2025 at 2:25 PM from V6 stated in part that R1 presented to the hospital with a closed right distal supracondylar femur fracture after getting right leg caught under wheelchair while someone was pushing her.R1's hospital summary report dated 08/06/2025 described R1's operative procedure as closed reduction and intramedullar nailing right distal femur on 8/5.The facility provided documentation to the Survey team on 08/12/2025 that outlined steps the facility began taking on 08/02/2025 to address the acceptable supervision for and proper use of assistive devices, such as a wheelchair, after R1's incident.Prior to the survey date of 08/11/2025 the facility had taken the following actions to correct the noncompliance:conducted an in-service training on the following topics:Proper Placement of Feet on FootrestsEmphasis on correct use of footrestsImportance of proper foot positioning during wheelchair useFall Prevention StrategiesIndividualized interventions and supervision tailored to resident needsReinforcement of fall prevention protocolsSafe Handling and Use of WheelchairsCompetencies and training completed for all nursing staffFocused on proper wheelchair use and resident safety during transfers and transportOn-going monitoring by (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 08/14/2025 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 0689 facility administration Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145969 If continuation sheet Page 3 of 3