Inspection·September 8, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred. This affected one of three residents (R6) reviewed injury of unknown origin. This failure resulted in R6 sustaining an injury to the right knee receiving seven sutures at the local hospital. Findings Include: R6 is a [AGE] year old with the following diagnosis: chronic venous hypertension with ulcer of the left lower extremity, venous, insufficiency, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. R6's Care Plan, dated 8/23/23, documents R6 has a potential for impairment of skin integrity related to fragile skin, impaired mobility, and incontinence. The Change of Condition Evaluation, dated 8/27/23, documents R6 had a change in condition of a skin wound and this occurred in the afternoon. R6 had no changes in mental status observed. There were no other changes of condition documented besides a skin tear to the right knee. The Hospital Records, dated 8/27/23, documents R6 was sent to the hospital when staff noted a linear laceration to the right knee. R6 does not have any pain and does not recall how this occurred. Staff denied any falls or witnesses to the injury. R6 was alert and oriented times two. The laceration to the right knee was 2.5 cm horizontally. R6 received seven sutures to the right knee during a laceration repair. On 9/6/23 at 5:35PM, V9 (Wound Nurse Practitioner) stated the older a resident becomes the more fragile skin becomes. V9 endorsed if a resident has a disease related to lack of circulation then wounds can develop easier than residents who don't have circulation issues. V1 stated the facility should be monitoring residents as best as they can to prevent any wounds. On 9/7/23 at 1:48PM, V2 (Director of Nursing/DON) stated when V14 (CNA) got R6 in bed, a skin tear was found to R6's right knee. V2 endorsed R6 was not able to say what happened. V2 reported assuming R6 bumped R6's leg, but was not able to confidentially say how the wound occurred. V1 stated the skin tear was about one to two inches long. V2 reported R6 was sent the hospital because of the skin tear and increased confusion. Per the documentation, R6 did not have any changes in mental status. V2 stated seeing a blood stain on R6's pants once R6 was in bed but was not able to see the blood stain before due to R6 having dark pants. (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: 145913 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 145913 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aperion Care Burbank 5701 West 79th Street Burbank, IL 60459 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)