Inspection·October 25, 2023

F 0686 Level of Harm - Actual harm amount of serosanguineous drainage. V4 (Registered Nurse, RN) stated during wound care, The discharge was coming from his sacral wound. Treatment is clean with soap and water and apply (ointment) and zinc, leave it open to air. It was noted R18's wound is open, with pinkish to reddish wound bed. Residents Affected - Few It was also observed 10:00 AM to 12:10 PM, R18 was lying on his back in bed, watching TV. On 10/23/23, random observation every 15 to 30 minutes interval was conducted from 10:10 AM to 12:48 PM, which showed R18 was not repositioned, nor was his sacral wound offloaded. From 10:10 AM to 11:00 AM, R18 was observed in bed, lying on his back in a semi-sitting position. From 11:15 AM to 12:10 PM, he was observed in bed, lying on his back, with head of bed elevated to a 90 degree-angle. From 12:35 PM to 12:48 PM, he was lying on his back again in a semi-sitting position. At 1:50 PM, he was again observed lying on his back, in bed. R18 was asked if he is turned or repositioned while in bed. R18 stated, No, I am not turned. When I'm asleep, I sleep on my side. But when I am awake, no, they don't turn me. On 10/23/23 at 12:56 PM, V7 (Wound Care Nurse) stated, He is verbal; does not like to be in the wheelchair. He was admitted with Stage 2 pressure ulcer on the sacrum on 07/24/23, healed on 08/30/23. No hospitalizations since admission. It reopened on 09/20/23 as Stage 3, measuring 7cm x 8cm x 0.2cm. It reopened because he is noncompliant with repositioning. On 10/23/23 at 1:39 PM, V6 (Certified Nurse Assistant, CNA) stated, He cannot turn himself, but he is willing to be turned. He is compliant with turning, awake and asleep. We do turning and repositioning every two hours. V4, Registered Nurse/RN was also asked regarding R18 and repositioning. V4 mentioned, We do side turning every two hours. He is able and compliant. On 10/23/23 at 4:23 PM, V9, Wound Nurse Practitioner stated, His sacral wound was healed on 08/30/23. It reopened to Stage 3 on 9/20/23. I don't have anything documented for the opening. Scar tissues are very fragile for reopening. After a wound is healed, it is prone to reopen. To prevent sacral pressure ulcer from developing and worsening, in general - turning and repositioning per protocol, in general about 2-3 hours; nutrition; use of low air loss mattress. I expect staff for early identification of skin issues and implementation of preventative measures like use of low air loss mattress, following up of nutritional status, offloading, turning and repositioning. R18's NP Wound Notes, dated 10/25/23, recorded: Wound status is open. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 6cm length x 9cm width x 0.1cm depth. There is a small amount of serosanguineous drainage noted. There is medium red, pink granulation within the wound bed. The periwound skin appearance exhibited: scarring, maceration, ecchymosis. 2. R29 is a [AGE] year old male, admitted in the facility on 07/13/23 with diagnoses of Hemiplegia, Unspecified Affecting Left Nondominant Side; Nontraumatic Acute Subdural Hemorrhage; Malignant Neoplasm of Prostate; Cerebral Infarction, Unspecified and Aphasia Following Cerebral Infarction. According to MDS (Minimum Data Set), dated 7/20/23, Section M, R29 was admitted with a Stage 3 pressure ulcer. R29's care plan, dated 09/06/23, regarding pressure ulcer on sacral buttocks documented: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 2 of 12 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 10/25/2023 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)

F 0686 Level of Harm - Actual harm Interventions: Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent positioning; Follow facility policies/protocols for the prevention/treatment of skin breakdown; Minimize pressure over bony prominences Residents Affected - Few R29's Skin Wound Report, dated 07/13/23, recorded: Stage 3 pressure injury on the sacrum, measurements of 1cm x 1cm x 0.1cm. R29's NP (Nurse Practitioner) notes documented the following: 07/26/23 - Integumentary: The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 2.5cm length x 2.5cm width x 0.1cm depth. 08/02/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 4cm length x 4.5cm width. There is large pink granulation within the wound bed. There is a small amount of necrotic tissue within the wound bed including eschar and adherent slough. 08/09/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 5cm length x 5cm width. There is a large amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited: scarring, maceration. On 10/23/23 at 12:56 PM, V7, Wound Care Nurse, stated, He is nonverbal; he is alert; he has a sacral ulcer, admitted with 07/19/23 his sacral wound increased in size to 2.5, he had multiple comorbidities, he had a history of head trauma. He had sepsis and infections; been in and out of the hospital. He also had prostate cancer. There were no recorded hospitalizations on R29 from 07/13/23 to 08/09/23 per census report. On 10/24/23 at 12:34 PM, V4 stated, He is turned every two hours. We put him in the reclining chair during daytime and stays there for about five to six hours. On 10/25/23 at 8:19 AM, V9, Wound Care Nurse Practittioner, was asked regarding length of time should a resident with sacral pressure ulcer can sit in the wheelchair or reclining chair. V9 stated, Residents who have pressure ulcers on the sacrum can be up and be put in wheelchair or reclining chair in two to four hours. Putting pressure on the sacrum will not allow blood flow. Blood flow facilitates wound healing. Facility's policy titled Skin Condition Assessment and Monitoring - Pressure and Non Pressure dated 6-8-18 stated in part but not limited to the following: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 3 of 12 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 10/25/2023 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for ensuring residents at risk for nutrition problems received adequate feeding supervision and assistance ,and failed to ensure consistent monitoring of meal intake. This failure applied to two of three residents (R51 and R157) reviewed for nutrition. Residents Affected - Few Findings include: 1. R51 is a [AGE] year-old female with a diagnoses history of Skin Cancer, and Anxiety Disorder, who was admitted to the facility 08/11/2023. R51's Current care plan, Initiated 08/12/2023, documents she has a diagnosis of cancer and is at risk for weight loss, pain, fatigue and other complications related to cancer with interventions including observe nutritional intake and refer to dietician as needed; she has a nutritional problem or potential nutritional problem with interventions including encourage oral intake of meals and snacks. R51's nutrition progress note, dated 08/14/2023, documents she is patient admitted following hospitalization for syncope, colitis, nausea and vomiting, and Bone Cancer post chemo with a diagnoses history of Skin Cancer, Hypertension, and Chronic Kidney Disease; her meal intake is good at 75-100% consistently. Estimated daily nutritional needs are 1923-2456 kcals. Plan including advise regular diet. Follow via referrals and reports. No other nutrition progress notes were available in R51's medical records from 08/15/2023 - 10/24/2023. R51's admission Minimum Data Set assessment, dated 08/18/2023, documents she requires supervision when eating. R51's initial Dietary assessment, dated 08/21/2023, documents she requires supervision with meals. On 10/23/23 at 12:10 PM, R51 stated she lost 85 pounds due to lack of appetite and chemo medications. R51 stated once in a while they'll give her a protein shake, but otherwise her daughter brings it to her. R51 stated she is not receiving any appetite boosters. R51 stated her oncologist is aware of this, and suggested to keep up on protein such as chicken and bananas. R51 stated the facility does nothing to help with her appetite issues. On 10/23/23 at 12:14 PM, V16 (Certified Nursing Assistant) collected R51's lunch tray, which was mostly untouched. V16 asked R51 if she was done eating, and after R51 responded yes, V16 collected her tray without cueing, prompting, or encouraging her to eat more. R51 stated her lasagna is too salty and some of the food at the facility is really nasty which is to be expected. R51 stated she believes the quality of the food quality is a cause of her not wanting to eat. On 10/24/23 at 12:25 PM, V17 (Certified Nursing Assistant) collected R51's lunch tray, which was 25% eaten, without observing how much she ate or prompting, cueing, or encouraging her to eat more. R51 stated to the surveyor she would drink small vanilla protein shakes every other day if provided to her. R51 stated she doesn't believe they are aware of her need to consume protein supplements. R51's current physician orders do not include a protein shake supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 4 of 12 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 10/25/2023 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R51's point of care reports for amount of food eaten from 10/01/2023 - 10/24/2023 documents she ate 75-100% of her lunch meal independently on 10/23/2023 and ate 51-75% of her lunch meal on 10/24/2023, which was inconsistent with the surveyors observations; and documents multiple meals with missing information regarding the amount of food eaten. On 10/24/23 12:44 PM, V2 (Director of Nursing) stated, (R51) is a cancer patient so we don't want her to lose weight unless she was obese. The CNA's (Certified Nursing Assistants) should be monitoring how much R51 eats because she eats independently, and inform the nurse of how much she ate as well as document the amount. the CNA's should prompt, cue, or encourage R51 to eat more or offer substitutes. V2 stated she has never heard of R51 complaining about the food. 2. R157 was an [AGE] year-old male, with a diagnoses history of Partial Paralysis Following a Stroke Affecting the Right Dominant Side, Pressure Ulcer of the Sacral Region, Dysphagia, Vascular Dementia, Metabolic Encephalopathy, Neuralgia and Neuritis, and Blindness in Right Eye, who was admitted to the facility 04/09/2023. R157's Most current care plan, initiated 04/09/2023, documents he has a self-care deficit with activities of daily living and requires assistance from staff with eating although the level of assistance is incomplete and unclear. R157's most current care plan, initiated 08/04/2023, documents he had a nutritional problem or potential nutritional problem, leaves 25% or more of my food uneaten at most meals with interventions including Monitor/document/report as needed any signs or symptoms of dysphagia including Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, or Appearing concerned during meals; Monitor/record/report to physician any signs or symptoms of malnutrition including Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months with interventions including: Provide, serve diet as ordered. Monitor intake and record each meal; Registered Dietitian to evaluate and make diet change recommendations as needed. R157's weight measurements from June - September 2023 document he weighed 262.0 pounds 06/01/2023 and weighed 245 pounds 09/01/2023 indicating a 6% weight loss in three months ,and weighed 258 pounds 08/01/2023, indicating a 5% weight loss in one month. R157's nutrition assessment, dated 08/02/2023, documents his Diet to be regular; His meal intake decreased from last review to <50%. R157's quarterly Minimum Data Set assessment, dated 08/15/2023, documents he required supervision and setup only for meals. Per R157's census report he was in the hospital from [DATE] - 08/24/23, 09/06/23 - 09/12/23, and on 09/14/2023. R157's nutrition progress note, dated 08/25/2023, documents he was readmitted with acute weight loss during hospitalization: down 5% since 8/1/23. He was readmitted following hospitalization for altered mental status, elevated troponin, decreased appetite/weakness for two days. Meal intake poor on readmission. R157 returned from hospital with diet consistency downgraded to pureed. R157's progress note, dated 8/25/2023 at 6:57 PM, documents he is alert with periods of confusion noted at times. During dinner, R157 was noted to have poor motivation to eat dinner meal. Various attempts of encouragement made. Writer attempted offering meal substitutions numerous times; however, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 5 of 12 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 10/25/2023 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R157 still continues to deny meal. writer will continue to encourage and motivate resident during meals. Family made aware of R157's poor oral intake. R157's nutrition progress note, dated 09/05/2023, documents he had significant weight loss (5%) since last month due to acute weight loss during hospitalization last month. Meal intake variable. R157 takes dinner poorly and refuses at times; staff to encourage and offer substitutes. R157's August and September 2023 point of care reports for amount of food eaten and eating ability documents he was receiving fluctuating levels of assistance from total dependence on two or more staff with eating to setup and cleaning assistance only, and fluctuating levels of meal intake from total refusals to 76-100% of meals with most meals ranging from 0-75% with or without staff assistance as well as multiple meals in August with missing information for amount of food eaten and eating ability. On 10/24/23 at 3:30 PM, V18 (Registered Nurse) stated R157 was a feeder. V2 (Director of Nursing) stated R157 was originally able to feed himself, but after one of his hospitalizations was not able to feed himself. V2 could not confirm when R157 was not able to feed himself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 6 of 12 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 10/25/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to follow professional standards of practice by not administering medications within the scheduled times ordered, failed to have a physician order before administering a medication, and failed to ensure that staff do not document medications as given in the electronic medication administration record (EMAR) without administering the medications to residents. This failure affected three residents (R18, R44 and R208) of five residents reviewed for medication administration and have the potential to affect all 51 residents currently residing in the facility. Findings include: 10/22/23 at 10:15AM, surveyor asked V4 (Registered Nurse/RN) if she is still passing medication, and she said she is done with med pass. During observation of the residents on the floor, R208 stated at 10:18AM, she has not received her morning medication. At 10:34AM, R44 also told surveyor he has not received his medication; he does not know what the delay is. At 10:40 AM, surveyor asked V3 (Licensed Practical Nurse/LPN) the assigned nurse for R44 and R208 if she is done with medication pass, and she said yes. Surveyor then informed her R44 and R208 stated they have not received their morning medication and she said, Oh, I think I have a few more residents on that end. At 10:40AM, followed V3 (LPN) opened her electronic medication administration record in the computer, and it showed all R208's morning medications have turned green in color. Surveyor asked V3 if the green color indicated the medications have been given, and she said yes. V3 prepared 9 pills for R208 and gave them to the resident, but did not sign the electronic medical administration record (EMAR) (because it was already signed). At 11:00AM, V3 started to prepare medications for R44, and again all his medications were already signed out as given. V3 prepared 6 pills for R44 administered them, and did not sign the EMAR. As V3 was leaving resident's room, he was coughing, and V3 asked him if he wanted cough syrup, resident said yes. V3 went to her medication cart and poured 10ml of Robitusssin cough syrup and administered it to resident. V3 was asked her why the residents' medications were signed out before being administered and she said, I was going to come back and give it, I was just busy this morning, I know I am not supposed to sign out the medications before giving them. The medications administered to R208 and R44 were scheduled to be given at 9:00AM. R44 did not any physician's order for a cough syrup per record review. Review of EMAR showed V3 signed out all the medications as given at 9:00AM. On 10/22/23 at 1:05PM, observed V4 (RN) for medication pass for R18, and noted the three due medications were already signed out as given before we got to the resident's room. V4 prepared three pills and administered them to the resident, did not sign the EMAR. V4 said, Oh, I must have clicked it in error; I am not supposed to sign the medications before they are given. On 10/23/2023 at 3:15PM, V2 (Director of Nursing/DON) said, Nurses must follow the five rights of medication administration: right medication, right time, right dose, right patient, and right route. Medications should be signed out after it is given; nurses should check the medication for the due time, administer the medications and then sign, this is done in case the resident refuses any of the medications so the nurse can document the refusal.4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 7 of 12 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 10/25/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete At 12:17PM, V2 said the facility requires a doctor's order before administering any medication to a resident, including cough syrup. Medication administration policy (undated) states in part, medications are administered as prescribed in accordance with good nursing principles and practice and only by persons legally authorized to do so. Under procedures 5. Five rights- right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Under administrations: 2. Medications are administered in accordance with written orders of the prescriber. 10. Medications are administered 1 hour before or after scheduled time. Documentation (including electronic), 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. Event ID: Facility ID: 145913 If continuation sheet Page 8 of 12 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 10/25/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were ten medication errors out of 25 medication opportunities resulting in a 40% medication error rate. This failure applied to four (R18, R44, R51 and R208) residents observed during the medication administration task. Residents Affected - Some Findings include: On 10/22/2023 at 10:50AM, observed medication administration for R208 with V3 (Licensed Practical Nurse/LPN). V3 opened her electronic medication administration record (EMAR) for the resident to prepare her medications, and the surveyor noticed the resident's medications are green in color, indicating they have been administered. V3 stated she was not supposed to sign off the medications before they are given. V3 then prepared nine different pills in separate medicine cups for the resident, and confirmed she has nine pills when surveyor asked her to confirm her own records. V3 administered the nine pills to the resident. Review of physician order for the resident during medication reconciliation showed the following medications that were scheduled for 9:00AM, were signed out as given at 9:00AM by V3 but were not administered to the resident during medication administration observation. 1.Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate)1 puff inhale orally two times a day related to unspecified asthma, uncomplicated. 2.Cetirizine HCl Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for Allergies, Carvedilol Oral Tablet 6.25 MG 3. (Carvedilol) Give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure. 4. Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 2 tablet by mouth one time a day related to major depressive disorder, recurrent, unspecified.5. hydralazine HCl Oral Tablet 100 MG (Hydralazine HCl) Give 1 tablet by mouth three times a day for vasodilator, lower blood pressure related to hypertensive heart disease with heart failure. 6. Norethindrone-Eth Estradiol Oral Tablet 1-35 MG-MCG (Norethindrone & Eth Estradiol) Give 1 tablet by mouth one time a day for Oral contraceptive, Treat menstrual bleeding. On 10/22/2023 at 11:00AM, observed medication administration for R44 with V3, and noted again the resident's medications in the electronic medication administration record (EMAR) are green in color and have been signed as given by V3. She prepared 6 medications for the resident and administered a 10ml of Robitussin cough syrup to R44. Per medication reconciliation, R44 have an order for the following medications that were signed out but not given: 1. Allopurinol Tablet 100 MG. Give 1 tablet by mouth one time a day for Gout related to gout, unspecified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 9 of 12 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 10/25/2023 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day related to retnetion of urine, unspecified. R44 does not have any physician order for Robitussin. On 10/22/2023 at 1:05PM, observed medication administration with V4 (RN for R18), and again noted resident's medications are green in color, already signed out as given. When presented with this observation, V4 said, I don't know what happened, I might have clicked them in error, I am not supposed to sign the medications before they are given. V4 prepared three medications and administered them to R18. Per medication reconciliation, R18 has an order for the following medication that was not administered: Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth three times a day related to Multiple Sclerosis. On 10/23/2023 at 3:15PM, V2 (Director of Nursing/DON) said, Nurses must follow the five rights of medication administration: right medication, right time, right dose, right patient, and right route. Medications should be signed out after it is given; nurses should check the medication for the due time, administer the medications and then sign. This is done in case the resident refuses any of the medications so the nurse can document the refusal. At 12:17PM, V2 said the facility requires a doctor's order before administering any medication including cough syrup to a resident. Medication administration policy (undated) states in part, medications are administered as prescribed in accordance with good nursing principles and practice and only by persons legally authorized to do so. Under procedures 5. Five rights- right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Under administrations: 2. Medications are administered in accordance with written orders of the prescriber. 10. Medications are administered 1 hour before or after scheduled time. Documentation (including electronic), 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 10 of 12 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 10/25/2023 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)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to follow their policy and procedure for providing dental services by not following up on the status of the dentist's recommendation for a tooth extraction for a dependent resident with a loose tooth. This failure applied to one of one residents (R26) reviewed for dental care. Residents Affected - Few Findings include: R26 is an [AGE] year old female with a diagnoses history of Cerebral Ischemia (Insufficient Blood Flow to the Brain), Apraxia Following Stroke, Parkinsonism, Abnormal Posture, Cancer of the Gastrointestinal Tract, and Dysphasia, who was admitted to the facility 02/27/2018. On 10/23/23 at 11:55 AM, V19 (Family Member) stated R26's loose tooth developed last year, and initially the facility wasn't going to have it pulled; then later was supposed to acquire a dentist, but there was no follow up to that. V19 stated he is concerned R26's loose tooth could fall out and she could accidentally swallow it and choke. V19 lifted R26's mouth open to reveal a front upper tooth loose. R26 was physically impaired, and unable to lift her own head up. R26's current oral/dental care plan, initiated 06/15/2023, documents she requires assistance and encouragement from staff with oral hygiene with interventions including discuss oral health concerns with resident/responsible party; report changes in oral status to physician; monitor effectiveness of medications/treatments as ordered. R26's dental consult form, dated 11/10/2022, documents V19 (Family Member) verbally agreed to extraction when in facility. Director of Nursing signed extraction consent form; patient understands that extraction of upper front tooth right of midline has been recommended due to not having alternative to extraction. Form includes both R26's son and dentist's signature. On 10/25/23 at 1:22 PM, V2 (Director of Nursing) stated once the Dentist comes, the facility relies on the Dentist to schedule the extraction. V2 stated if the Dentist never schedules the extraction, she doesn't know what would be the next step, because it's the Dentist's responsibility to schedule the extractions because they see residents once a month. On 10/25/23 at 1:49 PM V1 (Administrator) stated some of the Dentists will pull the teeth in the nursing facility, and if necessary, they will refer residents out to a specialist. V1 stated maybe the Director of Nursing should have followed up on the recommendation for R26's tooth extraction. V1 stated the Dentist the facility informed him R26 was not able to stand long enough for the x-rays, which is why they didn't complete the extraction. V1 stated the Dentist informed V1 they had notified V19 (Family Member) of this. V1 stated if R26 couldn't stand, the x-ray the facility would ask what the Dentist's recommendation would be for what would happen next, such as monitoring the tooth. V1 stated if the recommendation would be to monitor the tooth, the facility would monitor the tooth each day. V1 stated the importance of monitoring R26's tooth would be prevent ingesting the tooth, developing an infection in the area, or developing any pain in the area. The facility's Oral-Dental Care Policy, reviewed 10/25/2023, states: The purpose is To assess for the presence of absent teeth and state of oral hygiene and need for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 11 of 12 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 10/25/2023 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)

F 0790 referral to dentist. Level of Harm - Minimal harm or potential for actual harm Notify Social Service if Dental referral is needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 12 of 12