Health inspection·January 13, 2026

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to implement their abuse prohibition policy by failing to conduct a thorough investigation for an injury of unknown origin. This failure affects one of three residents (R1) reviewed for injuries of unknown origin. As a result, R1 was noted with swelling to the right lower forearm and grimacing in pain and was transported to the local hospital and R1 was found to have sustained a right comminuted distal radial fracture with displacement, a comminuted and impacted distal ulnar fracture with displacement, and a hematoma to the right side of the head.Findings includes:R1's hospital record, dated 9/22/25, notes R1 was brought in by EMS (emergency medical services) crew. Per EMS report, R1 had fall yesterday. This morning R1 had images which showed distal radius and ulna fracture. R1 states that she remembers falling yesterday. On physical exam by emergency room physician, a small hematoma was noted to R1's right lateral head; swelling noted to right wrist with obvious deformity. The emergency room diagnoses: fall and closed fracture of distal ends of right radius and ulna. The hospital's orthopedic surgeon was consulted and noted unclear, unwitnessed mechanism of injury given R1 is bedbound and has been for the last 3-4 years. Also noted is an injury to R1's head, deformity to wrist with dorsal prominence, and moderate swelling around wrist. R1's fracture was closed reduced and right arm placed in a splint.R1's hospital x-rays, dated 9/22/25, shows mildly comminuted (severe break where the bone shatters into three or more pieces, often from high-impact trauma, car accident or fall) fracture of the distal radial diaphysis with 1/4 shaft width radial displacement of the distal fracture fragment; mildly comminuted and impacted fracture of the distal ulnar metaphysis with 1/4 shaft width ulnar displacement of the distal fracture fragment; partially imaged osteoarthritis in knuckles and finger joints; and regional soft tissue swelling.There is no documentation found in R1's hospital record noting right arm injury due to pathological fracture.The facility's investigation into this incident only has statements from V3 RN (registered nurse), V4 RA (restorative aide), and V5 CNA (certified nursing assistant.) The facility did not present any further statements from other staff that worked on R1's nursing unit the days preceding the incident. The facility's investigation, dated 9/22/25, notes R1's right arm injury was due to a pathological fracture. The facility is unable to present any hospital documentation noting R1 had osteoporosis in right arm.On 1/8/26 at 9:45 AM, V1 (administrator) stated that R1 injured right arm when R1 hit arm on side rail. V1 stated that an investigation was done regarding this incident. V1 stated that all the nurses and CNAs (certified nurse aides) on R1's nursing unit were interviewed; all denied R1 falling.On 1/8/26 at 10:55 AM, V2 DON (director of nursing) stated she was present in facility at the time of R1's injury on 9/22/25. V2 stated that she was notified by staff and immediately went to R1's room to assess R1. V2 stated that R1 was not able to state what happened. V2 stated that she interviewed R1's roommates and was informed by one of them that R1 was rolling top sheet up and arm hit side rail. V2 stated that due to R1's comorbidities V2 believed right arm fracture was pathological. V2 stated that V2 called the hospital and asked if injury and R1's comorbidities Residents Affected - Few Page 1 of 2 145969 145969 01/13/2026 Aperion Care Forest Park 8200 West Roosevelt Road Forest Park, IL 60130

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could fracture be pathological fracture. V2 is unable to state the name of person and his/her job title that she spoke with at hospital. When questioned regarding the hematoma (a localized collection of blood outside of blood vessels, usually caused by injury or trauma) to R1's right lateral head noted on R1's hospital records on 9/22, V2 responded R1 did not have a hematoma, R1 has a dry flaky scalp.On 1/8/26 at 11:04 AM, V3 RN (registered nurse) stated that R1 only gets out of bed on dialysis days; Tuesdays, Thursdays, and Saturdays. V3 stated that R1 transfers via a mechanical lift device. V3 stated that R1 is very dependent on staff for ADLs (activities of daily living). V3 stated that V3 obtained R1's vital signs at beginning of day shift, R1's right arm was normal appearing. V3 stated that R1 received medications at 9:00 AM and R1's right arm was still normal appearing. V3 stated that V4 (restorative aide) informed V3 at 12:30 PM that R1 did not eat well for lunch and R1's arm was swollen. V3 stated that she assessed R1; R1's right wrist area was swollen and R1 was unable to move fingers. V3 stated that V3 does not recall if R1 was sent out for x-rays or x-rays were done in facility.On 1/8/26 at 11:25 AM, V4 RA (restorative aide) stated that when V4 walked past R1's doorway observed R1 was not eating. V4 entered R1's room to assist R1 with meal. V4 stated that he noticed R1 was grimacing. V4 stated that V4 attempted to give R1 fork to eat and observed R1's right wrist was swollen. V4 stated that V4 informed R1's nurse. V4 stated that R1 requires extensive assistance with repositioning. V4 stated that R1 gets up for dialysis via a mechanical lift device.On 1/8/26 at 11:55 AM, V5 CNA stated that he was feeding R1's roommate on 9/22/25 when R1 informed V4 that she was in pain. V5 does not recall any further details.R1's MDS (minimum data set), dated 8/27/25, section GG notes R1 requires extensive assistance with turning side to side in bed and is dependent on staff for all transfers.R1's abuse risk assessment, dated 8/27/25, notes R1 is at low risk for abuse. R1's abuse risk assessment completed post injury, dated 9/26/25, notes R1 is at moderate risk for abuse.The facility's abuse prevention and reporting policy, revised 10/24/22, notes, in part, an injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The final investigation report shall contain the following: conclusion of the investigation based on known facts. 145969 Page 2 of 2