Aperion Care Forest Park

F-F689 Interpretive Guidelines, documents the following for skilled nursing facilities: According to the Substance Abuse and Mental Health Administration (SAMHSA), opioid overdose deaths can be prevented by administering naloxone, a medication approved by the Food and Drug Administration to reverse the effects of opioids. The United States Surgeon General has recommended that naloxone be kept on hand where there is a risk for an opioid overdose. Facilities should have a written policy to address opioid overdoses.

The SAMHSA website houses a number of resources related to opioid management including this document intended for prescribers which addresses appropriate prescribing, monitoring for adverse effects, and treating overdoses: SAMHSA Opioid Overdose Prevention Toolkit: Information for Prescribers, https://www. samhsa.gov/resource/ebp/opioid-overdose-prevention-toolkit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 The Immediate Jeopardy that began on [DATE REDACTED] was removed on [DATE REDACTED] when the facility took the following actions to remove the immediacy. On [DATE REDACTED] the survey team verified by observation, interview, and record Level of Harm - Immediate review, that the facility implemented the following to remove the immediacy. jeopardy to resident health or safety Removal Plan:

Residents Affected - Few 1. Resident R11 has been reassessed and shows no signs of active substance use. DON and ADON, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED]

2. Resident R11's care plan reviewed. Administrator, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED]

3. All residents with a history of substance abuse have been reviewed by the Interdisciplinary Team (IDT) for care plans and interventions. Minimum Data Set (MDS) and Social Services, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED]

4. The facility has updated the substance use disorder policy to include post-Narcan administration monitoring, response to overdose, and when to indicate transfer. Chief Nursing Officer, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED]

5. Nurses are being retrained and competencied on how to respond to emergencies related to substance use including administration and monitoring after giving Naloxone, administering Cardiopulmonary Resuscitation (CPR) when appropriate, and hospital transfer as soon as possible before the start of their next shift. Nurses

on vacation or Family Medical Leave (FMLA) will be inserviced and competencied before returning to work. New Nurses will be inserviced and competencied during New Employee Orientation, prior to working directly with residents. Agency Nurses will be provided inservice material in their Orientation Packet that they receive prior to their first scheduled shift at Aperion Care Forest Park. ADON and DON, Initiated Date [DATE REDACTED], Completed date [DATE REDACTED] and Ongoing

6. A Quality Assurance Performance Improvement (QAPI) meeting was held with the medical director to discuss the incident with Resident R11, policy updates, and follow up. Administrator, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED]

7. During the monthly Quality Assurance (QA) Meeting, IDT will review ongoing training of nurses, review competencies and review any incidents of Narcan medication administration. QAPI Team, Initiated Date [DATE REDACTED], Ongoing monthly until [DATE REDACTED]

8. The facility will monitor the next 5 uses of Narcan, up until [DATE REDACTED] to ensure staff follow the updated facility policy on substance use. DON and ADON, Initiated Date [DATE REDACTED], Ongoing up until 5 Narcan uses or [DATE REDACTED].

9. The facility will randomly competency 3 nurses a week for the next 12 weeks to ensure they are aware of

the proper protocol for Narcan administration and substance use. Competencies will be added to Annual Nursing Competencies. DON and ADON, Initiated Date [DATE REDACTED], Completion Date [DATE REDACTED] and Ongoing

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33783

Residents Affected - Many Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents on two different floors. This failure affects 147 residents who reside on the third and fourth floors and has the potential to affect all 209 residents currently residing in the facility.

Findings include:

Facility census received upon survey entrance on 6/14/24, documents 209 residents reside in the building.

6/14/24 at 4:30PM, V3, Registered Nurse (RN) was asked about scheduling on the unit. Resident R3 said there are abut 74 residents and three nurses; the schedule said five certified nursing assistants (CNA's) but there are four; normally there are five to six CNA's. V3 added that she thinks someone called off. V3 said the fourth floor unit is busy because the residents on this floor have dementia, falls, and elopement risk. V3 said, management was told about this so they are trying to pull someone from another floor.

6/14/24 at 4:47PM, V4 (CNA) said, it's a short day. Normally we have six CNA's; when it's five, it isn't bad but four is short.

6/14/24 at 4:54PM, V5 (CNA) said, normally I work on the third floor but got pulled up to work on the fourth floor today from 3-11PM. I don't know about replacements.

6/14/24 at 4:57PM, V6, Licensed Practical Nurse (LPN)/Assistant Director of Nursing (DON) said, the scheduler is on vacation for two weeks and due back next week. We do use agency if needed and he usually sets it up.

6/14/24 at 5:25PM, V9 (CNA) said, we have four CNA's today; usually there are five, we should have five at least. Today each CNA has 18 residents a piece. We are each supposed to give three showers usually but when there's only four of us working it's not possible. There's only 15-20 people in here (eating in the dining room); the rest of the residents eat in their room, so the CNA's have to take their trays plus we have people who we have to help feed. No one is out there with the residents from CNA staff while we are in here fixing

the trays. V10 (CNA) stated, V8 (CNA) and I are both working doubles today - indicating V8 and V10 had already completed a shift this morning (7AM-3PM) and will now work the 3-11PM shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0725 The Facility Assessment with printed date of 01/16/24 did not include the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. Under Level of Harm - Minimal harm or Staffing section of Facility Assessment, Overall Staffing Number is 00 and number of staff listed under ADL's potential for actual harm (activities of daily living) is listed as Sufficient. Section B.1. Acuity - Sufficiency Analysis Summary includes Please document total #/average/range of staff required to ensure sufficient number of qualified staff are Residents Affected - Many available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance. It is to be noted that the referenced spreadsheet does not include number of staff needed; it only documents sufficient.

6/17/24 at approximately 4PM, V1 (Administrator) was asked about the facility assessment in regards to how

it is used for staffing. V1 said that it is the facility assessment they get from corporate and that is what they use. V1 did not elaborate on how facility assessment is used to determine staffing needs of the facility.

41692

On 6-16-2024 at 7:10am V20 (LPN) said, I am the nurse working on the fourth floor. I worked with only one Certified Nurse Assistant last night, it was a busy and rough night. Our current census is 76 patients; this is

the dementia unit.

Resident R8 is a [AGE] year-old male with medical diagnoses including hemiplegia, diabetes, and major depressive disorder. According to Minimum Data Set: Brief Interview for Mental Status (BIMS) reads score of 14/15, indicating Resident R8 is cognitively intact. Section GG personal hygiene, shower and bathe indicate Resident R8 needs substantial/maximal assistance.

On 6-16-2024 at 7:15am Resident R8 said, I need to be changed as soon as possible. The night shift only had one CNA and I was not changed at all after I was placed in bed at 8:00pm. I have urine and poop in the brief. I cannot wait any longer, I do not like to feel dirty and with bad odor.

On 6-16-2024 at 7:25am V23 (RN) said, I am a regular nurse on the 4th floor; working with one C.N.A is not acceptable. It is not enough help, we need at least three CNAs to provide the care the residents need.

On 6-16-2024 at 7:30am incontinence care was completed by V21 and V22 (CNA's) for Resident R8. V22 removed an undergarment that was visibly soiled with yellow and dark brown substance. V22 said, Resident R8 was very soiled;

this happens when the prior shift does not have enough people. It will affect the incoming shift; today is going to be a very busy day.

Resident R10 is a [AGE] year-old female originally admitted on [DATE REDACTED] with medical diagnosis that include and are not limited to: hemiplegia and hemiparesis following a cerebrovascular disease, diabetes, and major depression. According to Minimum Data Set: Brief Interview for Mental Status (BIMS) reads score of 15/15, indicating Resident R10 is cognitively intact. Section GG personal hygiene, shower and bathe indicates Resident R10 needs substantial/maximal assistance.

On 6-16-2024 at 7:45am Resident R10 said, last night it was very bad, we had only one CNA and I needed to wait a very long time because it was only one CNA working on the floor. I am very upset because I needed help and they did not come to help me. The issue of not having enough staff happens very frequently.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0725 On 6-16-2024 at 8:45am V6 Assistant Director of Nursing (ADON) said, I was not aware that we only have one CNA working on 11pm-7am shift on the 4th floor; having only one CNA is not enough on the floor. Level of Harm - Minimal harm or Having two CNAs on the 3rd floor is not enough help as they cannot provide the appropriate services. potential for actual harm

On 6-16-2024 at 10:00am V14 (DON) said, I was not aware that we only have one CNA on the fourth floor Residents Affected - Many and two CNAs on the third floor, having one CNA to 75 patients is not ideal. It is not what we want as they cannot provide the care that the residents need; that is common sense.

On 6-16-2024 at 10:55am V2 (Assistant Administrator) said, I am covering for the staffing coordinator since

he is on vacation. One CNA on the fourth floor is not enough help to care for the residents, we usually have at least three CNAs.

On 6-16-2024 at 11:17pm V30 (C.N.A) said, I worked by myself last night, it is very hard because I was not able to provide the care the patients needed. One CNA is on the floor for more than 75 patients. I can only do what I can do. I know some residents were not attended to last night.

On 6-17-2024 at 12:46pm V1 (Administrator) said, we do not have any staffing policy. V1 presented document [NAME]: facility assessment dated : 1-16-2024 under staffing it reads: Overall staffing: 00 activities of daily living: sufficient.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33783

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure that their facility assessment included a thorough evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the day-to-day needs of the residents. This failure affects has the potential to affect all 209 residents currently residing in the facility.

Findings include:

Facility census received upon survey entrance on 6/14/24, documents 209 residents reside in the facility.

On 6/14/24 at 4:30PM, V3 Registered Nurse (RN) was asked about scheduling on the unit. V3 said there are abut 74 residents and three nurses; the schedule said five certified nursing assistants (CNA's) but there are four; normally there are five to six CNA's. V3 stated she thinks someone called off. V3 said the fourth floor unit is busy because the residents on this floor have dementia, falls, and elopement risk. V3 said, management was told about this so they are trying to pull someone from another floor.

6/14/24 at 4:47PM, V4 (CNA) said, it's a short day. Normally we have six CNA's; when it's five, it isn't bad but four is short.

6/14/24 at 4:54PM, V5 (CNA) said, normally I work on the third floor but got pulled up to work on the fourth floor today from 3-11PM. I don't know about replacements.

6/14/24 at 4:57PM, V6 Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) said, the scheduler is on vacation for two weeks and due back next week. We do use agency if needed and he usually sets it up.

6/14/24 at 5:25PM, V9 (CNA) said, we have four CNA's today; usually there are five, we should have five at least. Today each CNA has 18 residents a piece. We are each supposed to give three showers usually but when there's only four of us working it's not possible. There's only 15-20 people in here (eating in the dining room); the rest of the residents eat in their room, so the CNA's have to take their trays plus we have people who we have to help feed. No one is out there with the residents from CNA staff while we are in here fixing

the trays. V10 (CNA) added a comment and said, V8 (CNA) and I are both working doubles today - indicating V8 and V10 already completed a shift this morning (7AM-3PM) and will now work the 3-11PM shift.

On 6-16-2024 at 7:10am V20 (LPN) said, I am the nurse working on the fourth floor. I worked with only one Certified Nurse Assistant last night, it was a busy and rough night. Our current census is 76 patients; this is

the dementia unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0838 Resident R8 is a [AGE] year-old male with medical diagnosis including hemiplegia, diabetes, and major depressive disorder. Resident R8's Minimum Data Set: Brief Interview for Mental Status (BIMS) reads score of 14/15, indicating Level of Harm - Minimal harm or Resident R8 is cognitively intact. Section GG personal hygiene, shower and bathe indicate Resident R8 requires potential for actual harm substantial/maximal assistance.

Residents Affected - Many On 6-16-2024 at 7:15am Resident R8 said, I need to be changed as soon as possible. The night shift only had one CNA and I was not changed at all after I was placed in bed at 8:00pm. I have urine and poop in the brief. I cannot wait any longer, I do not like to feel dirty and with bad odor.

On 6-16-2024 at 7:25am V23 (RN) said, I am a regular nurse on the 4th floor; working with one CNA is not acceptable. It is not enough help, we need at least 3 C.N.A's to provide the care the residents need.

On 6-16-2024 at 7:30am incontinence care observation was made for Resident R8 and was completed by V21 and V22 (CNA's). V22 removed an undergarment that was visibly soiled with yellow and dark brown substance. V22 said, Resident R8 was very soiled; this happens when the prior shift does not have enough people. It will affect

the incoming shift; today is going to be a very busy day.

Resident R10 is a [AGE] year-old female with medical diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, diabetes, and major depression. According to Minimum Data Set: Brief Interview for Mental Status (BIMS) reads score of 15/15, indicating Resident R10 is cognitively intact. Section GG personal hygiene, shower and bathe indicates Resident R10 requires substantial/maximal assistance.

On 6-16-2024 at 7:45am Resident R10 said, last night it was very bad, we had only one CNA. I needed to wait a very long time because it was only one CNA working on the floor. I am very upset because I needed help and

they did not come to help me. The issue of not having enough staff happens very frequently.

On 6-16-2024 at 11:17pm V30 (C.N.A) said, I worked by myself last night, it is very hard because I was not able to provide the care the residents needed. One CNA is on the floor for more than 75 patients. I can only do what I can do. I know some residents were not attended to last night.

On 6-16-2024 at 8:45am V6 (ADON) said, I was not aware that we only have one CNA working on 11pm-7am shift on the 4th floor; having only one CNA is not enough in the floor. Having two CNAs on the 3rd floor is not enough help, they cannot provide the appropriate services.

On 6-16-2024 at 10:00am V14 (DON) said, I was not aware that we only have one CNA on the fourth floor and two CNAs on the third floor, having one CNA to 75 patients is not ideal. It is not what we want as they cannot provide the care the residents need; that is common sense.

On 6-16-2024 at 10:55am V2 (Assistant Administrator) said, I am covering for the staffing coordinator since

he is on vacation. One CNA on the fourth floor is not enough help to care for the residents, we usually have at least three CNAs.

On 6-17-2024 at 12:46pm V1 (Administrator) said, we do not have any staffing policy. V1 presented document [NAME]: facility assessment dated : 1-16-2024 under staffing it reads: Overall staffing: 00 activities of daily living: sufficient.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 145969 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145969 B. Wing 06/23/2024

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 0838 6/17/24 at approximately 4PM, V1 (Administrator) was asked about the facility assessment in regard to how

it is used for staffing. V1 said that it is the facility assessment they get from corporate and that is what they Level of Harm - Minimal harm or use. V1 did not elaborate on how facility assessment is used to determine staffing needs of the facility. potential for actual harm

Review of Facility Assessment with printed date of 01/16/24 did not include the overall number of facility staff Residents Affected - Many needed to ensure sufficient number of qualified staff are available to meet each resident's needs. Under Staffing section of Facility Assessment, Overall Staffing Number is 00 and number of staff listed under ADL's (activities of daily living) is listed as Sufficient. Section B.1. Acuity - Sufficiency Analysis Summary includes Please document total #/average/range of staff required to ensure sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance. It is to be noted that the referenced spreadsheet does not include number of staff needed; it only documents sufficient.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 145969