Inspection·September 20, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few On 9/19/24 at 10:59am, R2 was observed alert to person, place, time, and situation, R2 observed sitting in a high back wheelchair. R2 said he was being washed up in bed, the girl told him to roll over, and he rolled too far and fell out of bed. R2 said he hit his head on the floor. R2 said it was one girl that was washing him up at the bedside. R2 observed with 2-inch laceration to the forehead with multiple sutures in place. R2 had purplish discoloration around the right eye and purplish discoloration under the left eye. R2 said he feels safe at the facility. On 9/19/24 at 11:37am, V1 (CNA-Certified Nursing Aide) said, I was giving (R2) a bed bath, I was washing (R2's) back, (R2) was laying on his left side, his back was facing me. (R2) turned a little more and fell out of bed. The air in the air mattress was increased on my side, and that contributed to pushing (R2) out of the bed. V1 said she did bring R2 closer to her before the turn, and R2 had room on the side of the bed for the turn. V1 said, The air in the air mattress always does that. V1 admitted to putting the air mattress on static mode when providing R2 care. V1 said, (R2) fell on the floor, he landed on the floor mat, but his head landed on the corner of the floor mat. V1 said she observed blood on R2's forehead. V1 said she went and got the nurse right away. V1 said she was on the opposite side of where R2 fell, and she could not catch R2 before he fell. V1 said R2 was not resisting to care. V1 said R2 is one assist with turning, repositioning, and bed mobility. V1 said the plan for R2 is to move his bed to the wall. V1 admitted the current plan of 2-persons assist with bed mobility for R2. V1 admitted the current plan of 2-person assist with turning and repositioning R2. On 9/19/24 at 1:50pm, V2 (Director of Nursing) said the facility does not put the air mattress on static mode during care / ADL care. V2 said after R2's fall, the facility plan is to use two people for turning and repositioning all residents that use an air mattress, regardless of body weight, V2 said this is for safety, it will prevent resident from rolling out of bed. On 9/19/24 at 2:42pm V4 (Restorative aide) said R2 need substantial to max assist with bed mobility, tuning from side to side. V4 said R2 needs two-person assist with bed mobility. V4 said R2 required two-persons assist prior to the fall. V4 said R2 sometimes does not want two people assisting him. On 9/20/24 at 10:13am V6 (Physical therapy manager) said R2 has weakness on his left side. R2 can roll to his left side but he will not stay in that position too long. V6 said she was not there when the fall occurred, she knows sometimes those air mattresses are slippery. R2's most current plan of care was presented by V2. R2's plan of care does not address the use of 2 person assist with bed mobility, does not address the use of two person assist with turning and repositioning while in use of air mattress. The operator's manual for R2's bed denotes, in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or position. The static mode will help ensure the patient does not bottom out when in a sitting position. Facility policy titled Fall prevention program, last revision date 11/21/2027, denotes 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 intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: methods to identify risk factors, methods to identify residents at risk, assessments time frames, (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 09/20/2024 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 - Actual harm use and implementation of professional standards of practice, communication with direct care staff. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Residents Affected - Few Facility Comprehensive care plan policy, with revision date of 11/17/17, denotes to develop a comprehensive care plan that directs the care team and incorporate the residents' goals, preference, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 3 of 3