Inspection·March 8, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few calls to let the staff know of the results, but sometimes they just fax the report. V8 said it is the nurse's responsibility to follow up on any x-ray results. V8 said she is unsure why R5 was not sent out when the x-ray results were received. On 3/8/24 at 1:54 PM, V2 (Director of Nursing) said if a stat x-ray is ordered, the x-ray company will arrive within 3 hours and she thinks they have 4 hours to read the x-rays and send the report. V2 said typically the x-ray company calls if there is a fracture, but sometimes they just fax the report. V2 said she is not sure why it took so long for the nurse to review the report and send R5 out to the hospital. V2 said sometimes if a resident has had a fall and is having pain, they would not wait for x-ray results, they would just send the resident to the hospital for evaluation. The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results Policy, revised on 3/14/18, shows, STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them .x-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: Pneumonia, New fracture. 2. R6's admission Record, (dated 3/8/24), shows she was admitted to the facility on [DATE], with a fracture of her left upper arm. R6's diagnoses include, but are not limited to, Alzheimer's disease, repeated falls, and syncope with collapse. R6's Order Summary Report (dated 3/8/24) shows and order from 1/18/24 whereby R6 is to keep a shoulder immobilizer in place. R6's Care Plan initiated on 1/18/24 shows R6 had an open reduction internal fixation (ORIF) (surgical repair) of her left upper arm bone (humerus) and should keep her shoulder immobilizer in place. R6's Fall-Initial Occurrence Note, dated 1/28/24, shows R6 had an unwitnessed fall in her room at 8:30 AM and was found lying on the floor. R6 reported pain to her right upper leg at a level of 7 on a 0 to 10 pain scale. R6 was sent to the hospital for evaluation and treatment. R6's Nurse's Note, dated 1/28/24 at 8:10 AM, shows R6 was found on the floor near her bedside with complaints of right leg pain. R6 was given pain medication, assisted back to bed, then the physician was notified and R6 was sent to the Emergency Department for evaluation. R6's Progress Note, dated 1/28/24 at 3:00 PM, shows R6 was admitted to the hospital with a diagnosis of closed, non-displaced fracture of her right femur. On 3/8/24 at 11:29 AM, V8, Registered Nurse (RN), said she was summoned to R6's room after the CNA (Certified Nursing Assistant) found R6 on the floor (on 1/28/24). V8 said she did an assessment of R6, and R6 complained of right hip pain. R6 said she and four staff members rolled a blanket under R6 and used it to lift R6 to her to bed. V8 said she then contacted the physician and was given orders to send R6 to the hospital. V8 said she called 911 and R6 was taken to the hospital by ambulance. V8 said she later contacted the hospital for an update on R6, and was told R6 had a hip fracture and would need surgery. On 3/8/24 at 12:04 PM, V2, Director of Nursing/DON, said if a resident is found on the floor, the nurse needs to assess the resident and if there is hip pain, they need to leave them on the floor. V2 said when the ambulance, (EMS) emergency medical services arrives, they need to immobilize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 2 of 3 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 03/08/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident and transfer them. V2 said staff should not move them because it could add insult to injury. V2 also said staff should never use a blanket to transfer a patient off the floor; it's not safe and they could drop the person. The facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy (revised 1/19/18) shows, .manual lifting is not permitted. Event ID: Facility ID: 145913 If continuation sheet Page 3 of 3