Inspection·March 29, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few a very brittle diabetic and at one point they found insulin vials and pens at his bedside. V6 said R1's wife admitted to administering insulin to R1 while in the facility. V6 said R1's wife was screaming at her saying no one was taking care of her husband. V6 said the morning R1 went to the hospital ([DATE]), R1 was lethargic and had slurred speech. V6 said R1's BG was, a little bit low. V6 said she had no idea how much, when, or what type of insulin R1 or his wife administered to R1. V6 said she does not remember R1's BG level, but it was low enough that the other nurse working that day administered glucagon to R1. V6 said glucagon starts working in less than five minutes. V6 said she did not call R1's provider about R1's BG. V6 said she would be concerned about any BG less than 70. V6 said she would check the BG again less than five minutes after glucagon is given to see if it was increasing and if it was still low, she would send a resident to the hospital immediately. V6 said she would consider a resident stable if their mental status was at baseline, the BG was between 70 and 100, and their vital signs were stable. V6 said R1's wife called the ambulance and demanded he be sent to the hospital. On [DATE] at 1:47 PM, V2, Director of Nursing, said standards of care would consider a BG less than 70 as low. The doctor would need to be notified and nursing would follow their instructions. V2 said he would recheck a resident's BG in 10 to 15 minutes after administering glucagon and if it was still low, he would administer a second dose of glucagon. V2 said he would err on the side of a resident's BG going too high rather than too low and risk a permanent medical condition from hypoglycemia. V2 said nurses document their medications on the electronic MAR as well as the BG checks. V2 said if something is not documented, then it was not done. V2 said nurses can use nursing judgment and critical thinking to determine if a patient needs to go to the hospital, they do not require a physician's order. On [DATE] at 10:20 AM, V10, R1's physician, said he knows R1 very well and he did not have slurred speech at his baseline. V10 said slurred speech is a sign of hypoglycemia or stroke. V10 said R1 was using insulin without permission. V10 said if the BG was less than 60, they should try giving glucagon and if able, feed the patient, and monitor the BG closely, especially with R1 as he had kidney issues which alone can cause hypoglycemia. V10 said an unknown quantity, type and time of insulin was given, so he could not say when it would peak or how long it would last. V10 said if large amounts of insulin were administered, even glucagon could not bring up the BG effectively. V10 easily needed to be closely monitored for 12-24 hours after the insulin overdose. V10 said if a patient's care or safety was compromised, he would send them to the hospital. V10 said if R1's speech remained slurred, he would try to give the glucagon once and if he did not return to baseline, he would send him to hospital. V10 said he would expect a BG to go to the 200s after receiving glucagon. V10 said a BG of 37, 58, or even 60 is not ok. V10 said he would not consider a BG to be stable in the range of 37 to 60. V10 said if the facility called and told him R1's BG did not go up to a normal range and he still had slurred speech despite being given glucagon and having eaten, he would have told them to send him to the hospital. On [DATE] at 11:20 AM, V11, R1's Nurse Practitioner, said R1's speech was not slurred, nor was he lethargic or groggy at his baseline. V11 said R1 was an alert and oriented, brittle patient who was noncompliant and difficult to work with. V11 said she was informed after the incident that R1 had been given insulin, but no one knows what type, when, or how much insulin was given. V11 said she could not even estimate how long the insulin would last. V11 said she would have given glucagon, and if R1 was not responding, she would have sent him to the hospital. V11 said someone cannot survive with a BG of 37. V11 said a BG of 37 to 60 is not stable; it's not safe for a person. V11 said a normal range for a BG is 60 to 100. V11 said the BG should be checked and repeated if it's not above 60 within 10-15 minutes. V11 said if she had been informed that R1's speech became slurred and his BG never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145171 If continuation sheet Page 2 of 4 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 145171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062 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 recovered to a normal range, she would have sent him to the hospital. Then V11 said, based on how R1 was as a patient, she would have sent him to the hospital anyway; he was noncompliant, not easy, and nothing good could have come out of this situation. V11 said she feels like patient safety is the most important thing. The nurses have a lot of patients on that floor that are very critical, and R1 could have probably died. V11 said the standards of care after an insulin overdose support that R1 should have been sent out to the hospital right away. R1's admission Record dated [DATE] shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, left ankle and foot osteomyelitis, type 2 diabetes with foot ulcer, non-pressure chronic ulcer of other part of left foot, cellulitis of left lower limb, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, peripheral vascular disease, atherosclerosis of native arteries of extremities, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery, hyperlipidemia, gout, diabetic polyneuropathy, obstructive sleep apnea, gastroesophageal reflux disease, anemia, muscle wasting and atrophy, abnormal posture, hyperparathyroidism, vitamin D deficiency, depression, left eye cataract, urinary incontinence and long term use of anticoagulants. R1's Minimum Data Set, dated [DATE] shows R1's speech clarity is clear with distinct intelligible words. R1's MAR for [DATE] to [DATE] shows one dose of Glucagon Emergency Injection Kit 1 milligram (mg) was administered to R1 on [DATE] at 10:00 AM. R1's Weights and Vitals Summary dated [DATE] shows R1's BG was 37 at 7:01 AM on [DATE], 60 at 7:54 AM on [DATE], and 57 at 10:05 AM on [DATE]. R1's BG averaged 163.55 between [DATE] and [DATE]; it was never below 89 during that time span. R1's Progress Notes show his BG was 37 when it was checked at 7:04 AM on [DATE] and R1 was awake and alert with three insulin pens/needles at the bedside. R1 admitted to self-administering insulin. The same note shows a recheck BG was 54. R1's Progress Notes show on [DATE] at 7:05 AM, R1 was responsive and appeared to be responding to treatment. On [DATE] at 7:54 AM, R1's Progress Notes show his speech was slurred. On [DATE] at 8:30 AM, R1's progress notes show he was eating breakfast, but his speech remained slurred. On [DATE] at 9:03 AM, R1's Progress Notes show R1's wife was updated on R1's status. On [DATE] at 9:05 AM, R1's Progress Notes show he spoke to his wife on the phone with slurred speech. On [DATE] at 9:55 AM, R1's Progress Notes show R1's wife was at the bedside, R1 was staring ahead, blinking his eyes and not answering questions. On [DATE] at 9:59 AM, R1's Progress Notes show R1's wife called 911. On [DATE] at 10:15 AM, R1's Progress Notes show R1 was being transported via 911 to the hospital Emergency Room. R1's Care Plan initiated on [DATE] shows R1 has potential for fluctuating blood glucose levels related to type 2 diabetes and his BG levels will be maintained within the parameters set forth by his physician. Signs and symptoms of hypoglycemia include a BG less than 70 and BG monitoring will be provided as ordered and as needed. R1's hospital records dated [DATE] show the Emergency Physician documented that R1 presented to the hospital with an insulin overdose. EMS found a low blood sugar on arrival and started R1 on an intravenous dextrose solution infusion. R1's initial BG at the hospital was 107, but later dropped into the 50 range. The Triage Note shows R1 was found catatonic upon EMS arrival with an BG check reading low. R1 was admitted to the ICU with diagnoses including, but not limited to insulin overdose and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145171 If continuation sheet Page 3 of 4 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 145171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062 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 hypoglycemia. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145171 If continuation sheet Page 4 of 4