Inspection·May 30, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement safety measures with Activities of Daily Living (ADL) as indicated in resident plan of care. This failure resulted in R1 sustaining a laceration on the left leg during transfer from wheelchair to bed with 6x4x2 measurements and being transferred to the local hospital for sutures. This failure also resulted in R2 sustaining intraparenchymal hematoma and transferred to local hospital. Findings Include: 1. R1's medical record documents: admission date 3/17/2025. Diagnosis Information include Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Radiculopathy, Lumbar Region, Need for Assistance with Personal Care, Subsequent Encounter for Fracture Without Routine Healing. R1's Care Plan Report read Focus: R1 have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day. Interventions: Chair/bed to chair transfer: R1 usual performance is dependent x 2, revision date 11/15/2024. R1 use a mechanical lift for transfer assist, Revision date 3/28/2025. R1's Minimum Datat Set/MDS Section GG, date 3/20/2025, indicates R1's Chair/bed-to-chair transfer as dependent defined as assistance of 2 or more helpers is required for resident to complete the activity. Facility Restorative General Information, dated 3/1/2025, indicates R1's Assist Status of X2, Sit/Stand. Facility Reported Incident, Final Report reads: On March 26th, 2025, while being transferred by CNA, (R1's) left leg bumped against the lever of the halo of her bed. A head to toe assessment was completed and noted with an open area on the left lateral lower leg area. Area cleansed thoroughly and dressing was applied; no LOC (level of consciousness) was noted and ROM (range of motion) remains at baseline. An order was received from MD (Medical Doctor) to send resident to ER (Emergency Room) for further evaluation. Resident returned from ER with sutures in place. Based on the investigation it was determined that (R1's) open area to her left lateral lower leg was due to her leg bumping into the lever of the halo on her bed during transfer. (R1's) bed, including the halo, was changed immediately and resident expressed feeling safe without further concerns. Minimum pain noted and managed with medications. (R1) continues to reside in the facility. Care plans were reviewed and updated by IDT (Interdisciplinary Team). MD and family made aware. R1's Hospital Record Discharge Instruction, dated 3/26/2025, reads: (R1) was seen today for a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 145913 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 05/30/2025 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)