Inspection·November 21, 2024

F 0689 reposition herself and rolled over to the floor. Level of Harm - Actual harm Review of V4 incident statement documents R1 observed on the floor. 911 called and transported resident to hospital for evaluation. V8's statement, as I was doing rounds at about 4:00 AM I walked into (R1's) room to do a safety check and (R1) was on the floor. (R1) stated she rolled out of bed and hit her head. Both statements are dated 10/24/24. No statement from V13 was provided. Residents Affected - Few Fire Department record, dated 10/24/24, documents, dispatched for the fall victim. Upon arrival crew located the patient laying supine on the floor. Alert and oriented times three. Patient's nurse stated the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell. Staff had already performed general wound care to the patient's forehead. Patient's history and meds was obtained from staff on scene. Call received at 3:43AM and ambulance on scene at 3:50AM. Hospital records, dated 10/24/24, presents with mechanical fall out of bed, (R1) states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground. (R1) head strike with frontal hematoma. Additionally pain in knee with a hematoma just below the right knee. Contracture and external rotation of right hip. Pain in right knee with hematoma over right tibial tuberosity. Mental status: Alert and oriented to person, place, and time. Neurological: positive for headaches. Imaging results for bilateral hips, pelvis, knees, right tibia and femur listed as results pending. Emergency Department Course: 10/24/24 agreeable to return to nursing home after irrigation and skin glue repair of laceration. On 11/19/24 at 10:01AM, R1 was observed in bed with a bump on the right side of her forehead, scabbed over in the center, pink skin, and dry without drainage. R1 was asleep. On 11/19/24 at 11:45AM, V4 said, The CNA (Certified Nursing Assistant) called me to the room. I went to the resident room; after assessing (R1), I called 911 because the physician told me to send her to the hospital. At baseline, (R1) is alert and oriented x 2, and she is very responsive and has periods of confusion. (R1) is a 2 person assist for transfers and she typically sleeps throughout the night. (R1) had been checked not long before the fall. Whatever I wrote is what happened. V4 said she didn't remember more than what was written. On 11/19/24 at 1:57PM, V8, CNA, said, I don't know who (R1) is. I don't remember someone falling and getting a goose egg or large bump on their head. I have had people fall but I don't know their names. Some people are 2 person assists because they are combative. On 11/20/24 at 12:54PM, V13, CNA, said, On 10/24/24, there was only 2 CNAs that night. V13 I was coming to east hall (opposite R1 hall) and the nurse called me and said they had a fall. I went in the room and (R1) was on the floor next to the bed. V13 said she was trying to change her diaper and she fell. The surveyor who is she? V13 said V8 by name. V13 said, (V8) told me she was trying to change (R1's) diaper in bed. I did not help in turning or changing R1 before the fall, I was on the East hall. They called 911 and I came back to my hall. On 11/20/24 at 11:50AM, R1 was in bed alert and oriented place and self, confused about time. The surveyor asked R1 what happened to her head? R1 she had a raised area, size and shape of an egg, with a scab in the center. R1 said her head and ankle hurt. R1 said, You should have seen it before; it was bigger and ugly. The girl was turning me and was pushing me, and I kept saying stop, you're going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor. V15, Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 2 of 6 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 11/21/2024 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 Residents Affected - Few of Nursing, was brought to the room, and R1 repeated the incident that the girl pushed her out of bed. R1 said, It hurt my shoulder and my head. R1 was on air mattress. R1's right leg was contracted, with knee bent, and foot towards R1's torso. R1's left leg extended out in front of her. On 11/19/24 at 12:11PM V5, CNA, said, (R1) needs 2 persons to turn her. (R1) can't help with positioning and is heavy, and 2 people are needed to turn her. We don't have a rail for (R1). I have not seen R1 kick, fidget, or try to get of the bed. (R1's) cognition goes in and out; she does get confused. On 11/19/24 at 12:49PM V7, CNA, said, (R1) is 2 persons assist for cares. (R1) never tries to get up or out of bed. (R1) can't roll out of the bed, and she can't help to turn. (R1) is cooperative. (R1) had a fall; when I came back to work R1's face was swollen, all on the right side was swollen. (R1) said they were trying to roll her over and she fell. (R1) told me that. It can be possibly true. (R1) can't sit up in the bed and she can't stand or doesn't try to walk. On 11/20/24 at 10:25AM, V11, MDS (Minimum Data Set) Nurse, said, When the fall was discussed with the team, we were told the fire department picked (R1) off the floor after the fall. Per the documentation, (R1) rolled off the bed. At 10:43AM, V11 presented Functional Ability assessment, dated 8/7/24. V11 said, (R1's) bed mobility is dependent. (R1) needs 2 person assistance. In the facility when someone is dependent, we use 2 people or more. (R1) has no behaviors that would mean she needs 2 persons for assistance. For turning and repositioning in bed, (R1) needs 2 people. (R1) has no strength in arms and legs. (R1) does not have the strength to turn herself in bed. I have no idea how she rolled out of bed. When they talked about the fall, I wondered too. Vased on our assessment, (R1) is dependent and can't roll herself. The binder at the nurses' station tells how many people can help. The staff gets trained to use 2 people. The staff is told if they use 2 people for the transfer, then they need to use 2 for bed mobility and changing briefs. On 11/20/24 at 11:07AM, V10, Restorative Nurse, said, Anyone with a fall risk score below a 9 are at risk. (R1) was not part of the falling leaf program when she fell, and she is not now. Based on assessments, (R1) needs extensive assistance with care; she needs a lot of help. (R1) cannot get up, she can assist with slight movement, but staff would need to do the turning. (R1) can be between 1 to 2 person assist with bed mobility, it depends on staff. I can do (R1) by myself. It is in the [NAME] in computer chart; you can see how much staff (R1) needs for care. V10 read from [NAME] and documented BED MOBILITY with assistance. V10 said, There is no direction if she needs 1 or 2 person, it depends on the person. Observation record will show if she has contractures. (R1) was not able to walk before the fall. I went over the fall. (R1) is on a bed mobility restorative program. The program says (R1) will practice repositioning in bed, and she does not use rails for program. On 11/20/24 at 12:03PM, V12, Restorative Aid, said, For (R1's) bed mobility, I go in and I turn her side to side, with another person at all times. I move her contracted leg as much as she can bear. (R1's) right leg is contracted and her left leg she does not bend. The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with (R1), she has never tried to roll or initiate the roll in bed. On 11/20/24 at 12:28PM, V15, Director of Nursing, said, I started last week. Paraplegia affects the ability to use legs. Facility fall prevention program, dated 11/21/2017, states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 3 of 6 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 11/21/2024 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program includes the following components: use and implementation of professional standards of practice. Care plan incorporates: Preventative measures. Safety interventions will be implemented for each resident identified at risk. Direct care staff will be oriented and trained in the Fall Prevention Program. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned in accordance with the plan of care. Event ID: Facility ID: 145913 If continuation sheet Page 4 of 6 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 11/21/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and records reviewed the facility failed to have accurate record of one resident's fall (R1). This failure affected one of three residents reviewed for accuracy of resident records. Residents Affected - Few The findings include: On 11/19/24 at 11:45AM, V4, Licensed Practical Nurse (LPN), note was with V4. V4 said, The CNA (Certified Nursing Assistant) called me to the room. Whatever I wrote is what happened. V4 said she didn't remember more than what was written. On 11/19/24 at 1:57PM V8, CNA, said, I don't know who (R1) is. I don't remember someone falling and getting a goose egg or large bump on their head. I have had people fall, but I don't know their names. On 11/20/24 at 12:54PM, V13, CNA, said, On 10/24/24, there was only 2 CNAs that night. I was coming to east hall (opposite R1's hall) and the nurse called me and said they had a fall. I went in the room, and (R1) was on the floor next to the bed. She was trying to change her diaper and she fell. The surveyor who is she? V13 said V8 by name. V13 said, (V8) told me she was trying to change (R1's) diaper in bed. I did not help in turning or changing (R1) before the fall, I was on the East hall. I did not give a statement for the fall. On 11/20/24 at 11:50AM, R1 was in bed, alert and oriented place and self, confused about time. The surveyor asked R1 what happened to her head? She had a raised area, size and shape of an egg, with a scab in the center. R1 said her head and ankle hurt. R1 said, You should have seen it before it was bigger and ugly. The girl was turning me and was pushing me, and I kept saying stop, you're going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor. R1 repeated the incident for V15, Director of Nursing, that the girl pushed her out of bed. R1 said, It hurt my shoulder and my head. R1 was on an air mattress. R1's right leg was contracted, with knee bent and foot towards R1's torso. R1's left leg was extended out in front of her. On 11/20/24 at 12:28PM, V15, DON, said, I started here last week. On 11/20/24 at 1:10PM, V14, Regional Nurse Consultant, said, 'we are going to investigate what (V13) and (R1) said. R1 has diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic). R1's Fall Initial, dated 10/24/24, noted R1 was noted on floor by CNA upon during rounds. Unwitnessed fall, precipitating and contributing factors: R1 confused, forgets to use call light and incontinent. New injuries observed raised area/ swelling/discoloration noted to right forehead. 911 called. R1's IDT Fall Committee Meeting Note: resident was observed on the floor and stated she wanted to reposition herself and rolled over to the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 5 of 6 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 11/21/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There is no record of R1 stating she was rolled out of bed during care to the facility during the fall investigation. Fire Department record, dated 10/24/24, documents, dispatched for the fall victim. Upon arrival crew located the patient laying supine on the floor. Alert and oriented times three. Patient's nurse stated the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell. Staff had already performed general wound care to the patient's forehead. Patient's history and meds was obtained from staff on scene. Call received at 3:43AM and ambulance on scene at 3:50AM. Hospital records, dated 10/24/24,documents, presents with mechanical fall out of bed, R1 states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground. R1 head strike with frontal hematoma. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145913 If continuation sheet Page 6 of 6