Inspection·August 15, 2024

F 0607 offender websites on 07/03/24, which was 5 days post admission. Level of Harm - Minimal harm or potential for actual harm R39 is a [AGE] year old, male, initially admitted in the facility on 08/03/24, with diagnoses of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Per facility's list of identified offenders, R39 is an identified offender currently residing in the facility. His name was checked under local and national sex offender registry on 08/13/24, which was 10 days post admission. His name was also checked under Department of Corrections on 08/13/24. Residents Affected - Many R46 is a [AGE] year old, female, admitted in the facility on 07/22/24, with diagnoses of Cerebral Palsy. CHIRP was conducted on 08/12/24. Her name was checked under state sex offender website on 08/13/24. CNAs (Certified Nurse Assistants) V11, V12, V13, V14, and V15, V16 (Housekeeping), and V17 (Cook) has no documentation on when state health agency registry was checked. Facility also was not able to provide documentation that sex offender and Department of Corrections websites were checked prior to employment. There was no documentation provided by facility if Office of Inspector General was checked prior to their start of work. On 08/13/24 at 10:25 AM, V5 (Admissions Director) was asked regarding residents' admission screening. V5 stated, We do the CHIRP on the day they were admitted . State and National sex offender registry sites should be checked prior to admission. On 08/13/24 at 11:36 AM, V1 (Administrator) was also asked regarding staff and residents' admission background checks. V1 replied, For Healthcare Worker Background Check, healthcare registry and websites should be checked on the day of interview, prior to hire. I have staff who checked the background the receptionist. No, we only checked the local department of health registry and nothing else. V4 (Receptionist) was interviewed on 08/13/24 at 11:50 AM regarding background checks on staff. V4 verbalized, I am the staff doing the background checks on staff and residents also. I didn't do any documentation except the registry. We only do the state health agency registry. We know that we have to check the sex offender websites; the Department of Corrections and others, but I did not do those. On 08/14/24 at 3:03 PM, V1 stated, Background checks on residents - we do CHIRP, sex offender websites; Department of Corrections prior to admission. For staff - we check the registry; sex offender websites and other sites on the day of interview. We do this to maintain patients' safety. On 08/14/24 at 4:16 PM, V25, Medical Director, stated, Staff have credentials and should be certified with what they are doing; facility should check background checks. We normally do it, that is the law, facility has to follow the protocol, it's the law and it is required. Facility's policy titled, admission of Identified Offender - Illinois, dated 1/24/18, stated the following: Guidelines: 1. Screened on Sex Offender web sites. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 2 of 15 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 08/15/2024 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 0607 2. Criminal History record information requested. Level of Harm - Minimal harm or potential for actual harm 3. Facility must review screenings and all supporting documentation to determine if the placement is appropriate. Residents Affected - Many Facility's policy titled, Abuse Prevention and Reporting - Illinois, dated 10/24/22 documented the following: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Conducting pre-employment screening of employees and pre-admission screening of residents Abuse Prevention: Pre-Employment Screening of Potential Employees Prior to a new employee starting a work schedule, this facility will: Check the Illinois Health Care Worker Registry on any individual being hire for prior reports of abuse, neglect or misappropriation of resident property, previous fingerprint results, and the sex offender website links on the registry; and Initiate an Illinois State Police live scan fingerprint check for any unlicensed individual being hired without previous fingerprint check. Pre-admission Screening of Potential Residents This facility shall check the criminal history background check on any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will: Request a Criminal History Background Check within 24 hours after admission of a new resident, Check for the resident's name on the Illinois Sex Offender Registration Website Check for the resident's name on the Illinois Department of Corrections sex registrant search page. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 3 of 15 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 08/15/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and implement interventions in preventing the development of pressure ulcer for one (R19) of three residents in the sample of 37 reviewed for pressure ulcer. This failure resulted in R19 developing an unstageable pressure ulcer on the sacral area. Residents Affected - Few Findings include: R19 is an [AGE] year old, female, initially admitted in the facility on 06/14/22, with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side; Parkinson's Disease without Dyskinesia, Without Mention of Fluctuations; and Neurocognitive Disorder with Lewy Bodies. R19's MDS (Minimum Data Set), dated 07/02/24, recorded: Section C, BIMS (Brief Interview for Mental Status) score of 99, which means R19 was unable to complete the interview; and Section M0150 Risk of Pressure Ulcers/Injuries - R19 is at risk of developing pressure ulcers/injuries. R19's Care plan on potential for alteration in nutrition, dated 09/06/23, documented: Intervention - Assess for changes in elimination, changes in skin integrity (04/02/24). Braden Observation, dated 01/03/24, documented a score of 16.0, which means R19 is at risk for development of pressure ulcers. Weekly Skin Observation, dated 08/05/24, documented R19 had intact skin. Her progress notes, dated 08/05/24, also documented intact skin. R19's shower sheets, dated July 2024, recorded normal skin. Shower sheet, dated 08/06/24, documented an open area on R19's sacrum. There was no documentation in the progress notes/wound notes, dated 08/06/24, addressing R19's open area on the sacrum. R19's Wound Assessment Details, dated 08/09/24, recorded an Unstageable Facility Acquired Pressure Ulcer on the sacrum with measurements: 2.7cm length x 2.4 width x depth unknown. R19's POS (Physician Order Sheet), dated 08/09/24, documented: Cleanse sacrum with wound cleanser then apply calcium alginate with silver then cover with foam dressing daily and PRN (when needed) one time a day for wound. On 08/12/24 at 11:40 AM, R19 was observed in the dining room attending activities. She was sitting in her wheelchair. R19 was awakeand alert, but did not respond when greeted. On 8/12/2024 at 1:10 PM, V24 (Wound Care Nurse) was observed performing wound care on R19. R19 was in bed, on a low air loss mattress, turned to left side, with a pressure ulcer on the sacral area. The sacral pressure ulcer had 30% slough, 70% granulation tissue, with clean wound edges. There was no discharge noted on the wound. Current measurements were taken as 2.7 cm (centimeters) x 2.4 cm. According to V24, R19's sacral wound is an unstageable pressure ulcer, facility acquired. V24 added, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 4 of 15 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 08/15/2024 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 0686 She had an old pressure ulcer healed on the sacrum, it reopened. She is nutritionally compromised and also incontinent. Level of Harm - Actual harm Residents Affected - Few On 08/14/24 at 11:05 AM, V23 (Wound Nurse Practitioner) stated, I was contacted a week ago regarding sacral wound; it is a facility acquired. The last time I saw her was last January 2024, she had a wound on the sacrum and was healed. It reopened 08/09/24 as Unstageable. I was first notified on 08/09/24, and I gave orders for calcium alginate. Facility has to follow its skin protocol. With fragile scar tissue, it can open in a matter of hours. On 08/14/24 at 11:10 AM, V24, Wound Care Nurse, stated, I am not here every day. When I came back on 08/09/24, I was informed that she has a wound on the sacrum. When I assessed it, it was Unstageable. I notified (V23) right away. If I am not here, nurses should notify Director of Nursing (DON), and she notifies (V23). On 08/14/24 at 11:15 AM, V6 (Registered Nurse, RN) stated, The CNAs (Certified Nurse Assistants) usually check residents' skin during shower and incontinence care. If there are any skin issues per CNA, I do the assessment myself and I tell DON. I also sent a message to the Wound Care Nurse. On 08/14/24 at 11:55 AM, V20, Certified Nursing Assistant/CNA stated skin assessments on residents are done during morning care and changing. If skin issues are noted, the CNAs notify the nurse on duty. On 08/14/24 at 12:23 PM, V2, Director of Nursing, stated, (V24) is the Wound Care Nurse, and she is not here every day. She works Mondays, Wednesdays, Fridays, and PRN (as needed). Floor nurses do wound care. The nurses and CNAs do the skin assessment. CNAs assess skin during ADL (activities of daily living) care. If there are skin issues, CNAs notify nurses. Nurses will do the assessment, and if there are open areas or redness, the nurse will call the Primary Physician and ask for orders or treatment orders. On (R19), the wound on the sacrum was identified by (V24) on 08/09/24 as Unstageable. I was not here that time. They just told me over the phone that she (R19) had an open area on the sacrum. I told (V24) to do the assessment and implement interventions and notify (V23). In the shower sheet, on 08/06/24, there was an open area. I believe (V22, CNA) reported it to the nurse. The nurse will document under wound observation note. Staff has to assess the body of residents on a daily basis. If they found any redness, they have to inform the nurse, and the nurse will check/assess and inform the doctor and put all the necessary interventions. There is a weekly skin assessment completed by treatment nurse. CNAs do the skin assessment and it is recorded on a daily basis via plan of care. The nurse who identified the skin issue will do the first treatment. V2 was asked to present documentation from the plan of care, dated 08/06/24, relative to R19's open area to the sacrum, but nothing was presented during the course of this survey. On 08/14/24 at 1:34 PM, V25 (Medical Director) stated, If a resident is not mobile, they have to move the resident every two hours or so, feed resident properly; change resident on time; and if there are skin issues, contact wound care team immediately. Facility's Policy titled, Pressure Ulcer Prevention, dated 1/15/18, documented the following: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 5 of 15 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 08/15/2024 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 0686 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 6 of 15 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 08/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one dependent resident (R21) was safely transported in a wheelchair. This failure affected one (R21) of two residents reviewed for falls in a sample of 37. This failure resulted in R21 falling forward out of a wheelchair while being pushed by staff, hitting R21's head, and sustaining a contusion to right forehead, requiring transfer to a local hospital for emergent care. Findings include: R21 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to generalized anxiety disorder, moderate intellectual disabilities, muscle wasting and atrophy, and history of falling. Minimum Data Set (MDS), dated [DATE], documents R21's Brief Interview for Mental Status (BIMS) score as 00, which indicates severe cognitive impairment. MDS, dated [DATE], also documents R21 is dependent on staff for wheelchair mobility and toileting hygiene; needs substantial/maximal assistance for oral hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear; needs partial/moderate assistance is needed for upper body dressing and personal hygiene; and needs supervision or touching assistance for eating. Fall risk assessments completed on R21 document the following: 11/20/2023 - Fall risk score =18; At risk for falls 02/19/2024 - Fall risk score = 14; At risk for falls 04/29/2024 - Fall risk score = 14; At risk for falls 07/12/2024 - Fall risk score = 16; At risk for falls 07/29/2024 - Fall risk score = 14; At risk for falls Care plan for R21, dated 11/21/2023, documents: Focus: I am at risk for falls and injury related to falls. I have history of fall. Risk factors: Requiring assistance with activities of daily living (ADL's), possible medication side effects, cataract, right leg cast in place. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to fall through next review. Interventions: All essential/personal items placed closer to bed and within resident's reach. Send to hospital for evaluation. Neurochecks as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 7 of 15 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 08/15/2024 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 0689 Bump to Forehead: assess for pain, provided pain interventions as appropriate. Level of Harm - Minimal harm or potential for actual harm Assess for altered cognition, decline in safety awareness. Assess for side effects of medications. Residents Affected - Few Assist with ADLs, anticipate and meet resident's needs. Assist with toileting upon awakening, before and after meals, during rounds and before bedtime. Progress note, dated 07/12/2024, documents: While (V31) Certified Nursing Assistant (CNA) was wheeling (R21) back to his room; (R21) abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. Certified Nursing Assistant unable to prevent fall in a timely manner due to resident's abrupt agitated behavior. Upon staff interview of incident, (R21) stated, 'I wanted her (referring to V31) to wheel me faster back to my room.' (R21) assisted safely back to wheelchair. Vital signs taken. Body assessment completed with discoloration/redness noted to the right side of forehead. Pain assessment completed with no complaints of pain made. Range of motion assessed and within resident's baseline. Level of consciousness within resident's normal range. First aid rendered to affected site per medical doctor (MD) orders. Neuro checks initiated. (R21) assisted safely to bed. Activities of daily living (ADL) care rendered. Bed in lowest position with call light in reach. MD made aware and gave orders to send (R21) to hospital for further evaluation. MD orders carried out. (V32) Case worker made aware. Plan of care ongoing. Progress note, dated 07/12/2024, documents: (R21) is being transported via ambulance to hospital. Order summary with signed bed hold policy sent with (R21). Report called and given to emergency room nurse. MD made aware. (V32) made aware. All departments made aware. Local hospital emergency room note dated, 07/12/2024, reads: [AGE] year-old man with history of hypertension, hyperlipidemia, benign prostatic hypertrophy, failure to thrive, not on blood thinners here for evaluation of head injury. Patient coming from facility after falling out of wheelchair, hit head, sustained small contusion to right forehead. Fall initial occurrence note, dated 07/12/2024, documents description of occurrence: While CNA (V31) was wheeling resident back to his room; resident abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. CNA (V31) unable to prevent fall in timely manner due to resident's abrupt agitated behavior. On 08/12/2024 at 10:04 AM, R21 was sitting at table in a wheelchair in the activity room. Bruise noted to forehead, purple in color, and slightly smaller than quarter sized. On 08/13/2024 at 9:54 AM, R21 was in a wheelchair in activity room. Bruise remained purple in color and remained slightly smaller than a quarter in size. On 08/13/24 at 10:07 AM, V6 (Registered Nurse) stated, The bruise on his forehead is from his fall last July. The bruise did not fade out. He has not had any falls since last one in July. He sometimes is a bit aggressive with movement, but not all the time. No aggressive attitude. Bruise has remained since fall last month. It was a little bigger, not much. When asked what interventions are in place to keep him safe, V6 stated he had fall mats and low bed in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 8 of 15 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 08/15/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/14/24 at 9:49 AM, (V2) Director of Nursing (DON), stated, The bruise on (R21's) forehead has been there since his fall on 07/12/2024. It doesn't heal. He keeps messing with his face. He has not had a fall since the one in July. On 08/14/24 at 3:39 PM V29, (Certified Nursing Assistant/CNA), stated, I have worked here about a month. I have worked with (R21). He is a fall risk. The interventions we have in place are place call light in reach, lower his bed, and floor mats. I can't think of anything else at the moment. He does not have any behaviors. I am not aware of any falls. On 08/14/24 at 12:43 PM, V27 (CNA stated, I have worked here 3-4 months. I have taken care of (R21) before. Sometimes he gets a little aggressive. Nothing too crazy. Sometimes when someone sits where (R21) wants to sit, he makes noises or will ball up his fists and shake them. I have not been here when he has had a fall. I know (R21) is a high fall risk. The interventions we have in place are that we get (R21) up so someone is watching him. Staff is always in the activity/dining room so we can watch (R21). I am not aware of any other interventions in place to keep him from falling. On 08/14/24 at 11:57 AM, (V2) Director of Nursing (DON), stated, (R21) is confused. He can't walk and does not want to go to another facility. He loves it here. He has a lot of pictures. He has behaviors sometimes. He is resistive with care or does not want to be put to bed. He sometimes become restless. He has had 2 falls. The first one he rolled over on his bed, and the last one, (V31) was wheeling (R21), and he became restless and leaned forward and ended up on the floor. We sent him out to the hospital. The family is very concerned about him. They want him to be sent out to hospital for any fall. He sustained bruising to the head. He hit is head when he hit the floor. Sometimes he is just restless once in a while. When he is in bed he just moves around once in a while. He sometimes looks for his pictures, and if they are on the floor, he will try to get them. CNAs know if his pictures on the floor, to pick up and give to him because he will look for it. When he gets restless like that, we give him time and talk to him. He started to move that time in the wheelchair, and he lost his balance in the chair. A lot of times he is in the dining area, and he is leaning on the table. We are careful with him because he is leaning a lot of time without a table in front of him. We have people all the time in the dining room to watch him. I tell them to always check on (R21). He is high risk for falls. Interventions when he is in bed his bed is in low, low position and we have a floor mat, and always redirect him. When he is restless, we give him space and redirect him. We listen to him. We tell him to always stay by the table. He is alert with confusion. He is total care. He is dependent with all ADLS. Eating is fine, but he is total assist for everything else. When a risk assessment is 14-18, that means high risk for falls. For (R21) is high risk. Care plan states he has poor safety awareness. He is not aware what he is doing. V2 was asked when V31 was pushing him did he have leg rests? V2 replied, I am not sure. (R21) was sent out to the hospital; we did not report because it was no injury. His hematoma to forehead is not serious so we did not report it When asked, what is your expectation for CNA's? How should they propel resident in wheelchair? V2 responded, They should make sure resident is safe and tell them what they are doing and make sure they are not moving. Yes, if he leans forward, the CNA will tell him to lean back. The expectation is for the CNA to transport safely, so the resident is safe and does not get harmed. V2 was sked, When he fell on July 12, what intervention did you add to prevent further falls? V2 replied, We make sure to ask for assistance, and to stop pushing the chair. On 08/14/2024, investigation was provided, conducted by V2 regarding R21's fall on 07/12/2024. Investigation includes statement from V31 as follows: While I was wheeling resident back to his room; all of a sudden he became agitated and slide his body down landing on the floor and bumping his head. It happened so fast and I couldn't get to him fast enough. I then made sure he was safe and called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 9 of 15 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 08/15/2024 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 0689 for the nurse to see him. Level of Harm - Minimal harm or potential for actual harm On 08/14/24 at 4:16 PM, V25, Medical Director, stated. I have been Medical Director since about 2015. I am not by the computer, but I can try to log in. I remember most of my patients, but do not remember everything. I am logging in now. I recall the name (for R21), but I want to be sure. I get calls on everything that happens. I am sure I was called regarding his fall. He has anxiety and dementia no other psych diagnoses. The psychiatrist would be better to ask that question. When asked what is the expectation MD has of staff regarding falls, he stated, Obviously they need to be assessed and sent to the hospital, and they will do evaluation and testing. When asked if this fall could have been prevented? V25 stated, Obviously they could have held them from falling forward. Did you ask the CNA? If I am on the street and see someone falling, I will try and prevent it. I think everyone will try to do that. I have not seen behaviors whenever I have seen him. Residents Affected - Few Fall Prevention Program Policy, dated 11/28/12, states: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice. Standards: Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program Transfer conveyances shall be used to transfer residents in accordance with the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 10 of 15 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 08/15/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent prior to administering a psychotropic medication for one (R17) of five residents reviewed for unnecessary medications in a sample of thirty-seven. Findings include: R17 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses that include but are not limited to: Dementia, major depressive disorder, schizophrenia, and Alzheimer's disease. Medication order, dated 05/27/2023, documents order as: Lexapro Oral Tablet 20 mg - Give 0.5 tablet by mouth in the morning related to Major Depressive Disorder. Medication consent, dated 05/28/2023, documents Lexapro 0.5 mg tablet. On 08/14/24 at 11:57 AM, V2, Director of Nursing (DON), stated, Every one of us is in charge of psychotropic medication. I am DON so I am in charge. For (R17), her order is for 10 mg Lexapro. Stock is 20 mg, but her order is for 0.5 tab so 10 mg. This consent is not correct. It should be for 0.5 tab of 20 mg, not 0.5 mg tablet. I believe this is the only consent I have for this resident for Lexapro. This consent is not correct. I believe this is just a clerical error. I cannot answer for that nurse, and I did not check it either, so yes, it is wrong. It is written there. The consent should read Lexapro 20 mg - 0.5 tablet. It is confusing for my nurses, but the consent is wrong. We have the order, but the consent is wrong. On 08/15/24 at 12:41 PM, V2, DON, stated, I did not have any other consents for (R17) other than what I already provided to you. Psychotropic Medication-Gradual Dosage Reduction Policy, dated 11/28/12, documents: Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. Guidelines: Informed consent shall be obtained as follows: a) Psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 11 of 15 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 08/15/2024 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 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 review, the facility failed to provide routine dental services to meet resident's needs. This failure applies to three of six residents (R41, R51, and R30) reviewed for dental services. Residents Affected - Few Findings include: 1. R41 is a [AGE] year-old, male, initially admitted in the facility on 12/22/22, with diagnoses not limited to Chronic Respiratory failure with hypoxia, Chronic Congestive Heart Failure, Severe Protein with Malnutrition, and Chronic Kidney Disease stage 3. On 08/12/24 at 10:41 AM, observed R41 with missing and discolored teeth. R41's current oral/dental care plan, initiated 09/13/2023, documents he exhibits dental/mouth problems as evidenced by: some missing/broken natural teeth and has the potential for further alteration and/or complications related to it; continue all interventions including Coordinate arrangements for Dental care. There was no documentation in R41's medical records of being seen by the Dental Hygienist from June 2023 to August 2024. R41's dental consult, dated 06/13/2024, documents he was not seen by the dentist because he was in the hospital. 2. On 08/13/24 at 7:20 AM, observed R51's teeth with heavy tarter buildup and abnormal in appearance. R51 stated the staff don't clean her teeth, and she has lost some teeth since she's been in the facility. R51 is a [AGE] year-old female, initially admitted in the facility on 04/11/24, with diagnoses not limited to dysphasia, Type 2 Diabetes with out complications, Parkinson's Disease, and Systemic Lupus Erythematosus R51's current oral/dental care plan, initiated 04/11/2024, documents she has Impaired Dentition; obvious or likely cavity or broken natural teeth, continue interventions which include Coordinate arrangements for dental care as ordered. There was no documentation in R51's medical records of being seen by the Dental Hygienist from April 2024 to August 2024. 3. R30 is a [AGE] year-old female, initially admitted in the facility on 10/23/2018, with diagnoses not limited to Chronic Respiratory failure with hypoxia, Vitamin D Deficiency, Cerebral Ischemia, and Alzheimer's Disease with early onset. On 08/12/24 at 10:41 AM, R30 was sitting in the dining area; observed her to have missing, discolored teeth and tarter buildup. R30's care plan, initiated 10/13/2023, for oral/dental care documents she has an alteration in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 12 of 15 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 08/15/2024 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 0790 Dental status (broken or carious teeth). Level of Harm - Minimal harm or potential for actual harm There was no documentation in R30's medical records of being seen by the Dental Hygienist from June 2023 to August 2024. Residents Affected - Few On 08/14/24 at 11:12 AM, V2 (Director of Nursing) stated, Upon admission, residents receive an oral assessment and residents who require dental care are referred to the dental provider. All residents need to be seen by the hygienist because this is part of their services. When the hygienist comes to the facility, they are given the current census for that day, and will also be informed if there are any residents who need to be prioritized based on their dental status. If a resident is not available when the hygienist comes to the facility, Social Services is informed so that the resident is prioritized when the hygienist returns. When the dental hygienist or dentist sees residents, a report is provided to the facility for that visit. If residents refuse dental care, their families are notified and asked to assist with encouraging the residents to receive dental care. (R41), (R51), and (R30) have no history of refusing dental care. V2 stated R51 was admitted to the facility in April 2024, and she is not sure why she wasn't seen by the dental hygienist on 06/13/2024, when other residents were seen. V3 (Social Services Director) stated, The Dental Hygienist comes to the facility every three months and was last at the facility in June. When the dentist or hygienist sees residents and provides reports for those residents, the reports are uploaded to the resident's chart. On 08/14/24 at 3:50 PM, V1 (Administrator) agreed residents should be seen by the dental hygienist for regular cleaning. V2 (Director of Nursing) could not explain why R51 was not seen by the Dental Hygienist on 06/13/2024, although V2 confirmed she had returned to the facility from the hospital from the previous day. Email communication from the facility's Dental Provider to the facility, dated 08/14/2024, documents: Residents who are active on our dental program are seen about every three months by the dentist for an exam and also seen monthly, or every other month by the hygienist for a cleaning. They are able to see any resident at the facility for an assessment at no cost, even if the resident is not active on our dental program. The dentists and hygienists submit all of their visit notes in our clinical portal. These notes are sent to the facility as well. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 13 of 15 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 08/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing and storing food under sanitary conditions by not ensuring all staff entering the kitchen wore hair restraints, not discarding food past their used and best by dates, and not keeping the food prep area free of potentially contaminated objects. This failure applies to all 55 residents in the facility. Findings include: On 08/12/24 at 9:25 AM, a sign was on the door entering the kitchen stating hairnets must be worn when entering the kitchen. Observed multiple grilled cheese sandwiches with a use by date of 08/11/2024, and a fat free milk carton with best buy date of 08/08/2024 stored in the refrigerator. V17 (Cook) stated the grilled cheese sandwiches and milk carton should have been removed from the refrigerator. 16 fat free milk cartons, with a use by date of 08/11/2024, were stored in the freezer. On 08/12/24 at 11:02 AM, a personal phone was on the food prep table, where rolled up silverware were placed that were being used for lunch. V4 (Receptionist) walked through the kitchen twice without donning a hair net. A personal phone and car keys were on the top level of the food prep table where V28 (PM Cook) was preparing tuna. The facility's Hair Restraint Policy received and reviewed 08/14/2024 states: Staff shall wear hair restraints in all food production areas. The facility's Food Storage Policy received and reviewed 08/14/2024 states: Food shall be stored at appropriate methods to ensure the highest level of food safety. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. The facility's HACCP (Hazard Analysis and Critical Control Points) and Foodborne Illness Policy received and reviewed 08/14/2024 states: Physical hazards are part of the potential hazards that are typically the cause for food contamination. Physical hazards are foreign objects such as hair and dirt that inadvertently get into food. According to the CDC (Centers for Disease Control), using contaminated equipment has been identified among the common factors that are responsible for foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 14 of 15 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 08/15/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not ensuring garbage and waste disposal in the food prep was covered when not in use. This failure applies to all 55 residents in the facility. Residents Affected - Many Findings include: On 08/12/24 at 9:25 AM, surveyor observed gnats in the kitchen, and a large garbage bin next to the food prep area open without the lid when not in use. On 08/12/24 at 11:02 AM, surveyor observed a large garbage bin next to the food prep area, open without the lid when not in use. The facility's Garbage and Rubbish Disposal Policy received and reviewed 08/14/2024 states: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 15 of 15