Inspection·May 5, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement fall prevention interventions for a resident at high risk for falls for one (R1) out of three residents reviewed for falls in a total sample of three. These failures resulted in R1 had an unwitnessed fall on 04/01/2025. R1 sustained a left femur fracture. Findings include: Facility's final reported incident (FRI) report dated 4/2/25, documents in part, resident (R1) is alert and oriented to name. R1 needs consistent verbal cueing and reminder. R1's gait is unsteady, requires staff's assistance for transfers and ambulation. On 04/01/2025 at approximately 5:00 AM, resident (R1) observed in the room near bathroom on buttocks next to wheelchair. At 8:33 AM, nurse assessed R1 during am (morning) care and noted resident refusing to get out of bed. Resident stated, tengo dolor (Spanish translated to English means I have pain), while pointing to his lower back. Follow up with hospital revealed resident sustained a left femur fracture. R1's nurse's note dated 4/1/2025, 9:40 PM, documents in part called the hospital, resident (R1) being admitted with diagnosis of left femur fracture. On 05/03/2025, at 2:11 PM, V9 (Certified Nursing Assistant) states that V9 is not familiar with R1's care. V9 states I barely work on that floor; I (V9) do remember that night. I remember R1 kept pulling the call light, but R1 didn't want anything, every time I (V9) would go in there, R1 was just sitting on the edge of the bed. I did provide him with fresh water. V9 reports that when R1 had the fall, R1 was by the washroom, as if he was trying to go to the bathroom. V9 states I don't remember exactly if I changed R1 or if I took R1 to the washroom. I am not sure if I got a chance to document on him (R1) that night. V9 states that V9 did not know that R1 was a fall risk. V9 continues to state I know about the fall binder, but I did not look at that binder that night. V9 reports that it is important to know if residents are at high risk for falls to make sure the staff take the proper precautions, so the residents don't fall. On 05/03/2025, at 1:05 PM, via telephone V8 (Restorative Director/Licensed Practical Nurse) states that when V8 went to investigate R1's fall, R1 said he was trying to go to the washroom. V8 states from my knowledge he does not ambulate. He requires assistance with ADLs (activities of daily living) and mobility. On 5/5/2025, at 3:28 PM, via telephone V12 (R1's Attending Physician) states R1 has history of falls, and a history of dementia. V12 states that residents can suffer a fracture from a fall. (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 3 Event ID: 146001 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 146001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care International 4815 South Western Ave Chicago, IL 60609 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)