Inspection·October 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Depression; and anxiety disorder.According to R4's MDS (Minimum Data Set) assessment dated [DATE] under section C, R4 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderately impaired cognition. On 10/22/2025 at 11:00 AM Based on facility's record, R2 was discharged from the facility on 10/21/2025 and is not available for observation nor interview during this investigation.On 10/22/2025 at 11:05 AM Surveyor observed 3 mm laceration on R1's right upper lip and bruise on the right lower lip. R1 said, Yesterday (10/21/2025) around 8:30 AM, I was going for a smoke to the east side of the second-floor unit, where smoking room is located. There were several other residents chain smoking in the smoking room, so I said something about it. R2 heard me talk, didn't like what I said, came out of the smoking room, and hit me. It happened in the hallway, right in the front of the smoking room. It went from a verbal to physical altercation. R2 walked away and I went to the nursing station to let the nurse know that R2 hit me. The nurse gave me ice pack and some pain medication. I also called the police. The police came a few minutes later, took my statement and said they will ticket R2. I was also sent to the hospital. They irrigated my wound, gave me a shot, and sent me back to the facility. I don't know what they're doing with R2, they (facility staff) are not telling me. I'm subconsciously afraid, half of those people (residents) here, are mentally ill, you never know what they're going to do.On 10/22/2025 at 11:22 AM Surveyor observed smoking room on the east side of the second-floor unit. The smoking room monitored by staff via an outside monitor connected to the camera placed in the smoking room. V3 (Certified Nurse Assistant/Monitoring Staff) said, The smoking room is monitored most of the time. Different staff are assigned to monitor it. I know the smoking room is not consistently monitored but not exactly sure when it's not. On 10/22/2025 at 11:36 AM V4 (Licensed Practical Nurse) said, Yesterday (10/21/2025) between 8:25 AM and 8:30 AM, I heard shouting while I was preparing medications in the nursing station. I walked out of the nursing station and around the corner and saw R1 pointing at R2 and saying, He punched me. I attempted to ask R2 what happened, but he just kept walking. I then gave R1 ice pack and called for R1's assigned nurse. In the meantime, R1 called local police. I notified then V1 (Administrator/Abuse Prevention Coordinator), V2 (Director of Nursing), and a social worker. I'm not sure if I saw any staff present by the smoking room when I responded to the incident between R1 and R2, it was morning, so CNAs (Certified Nurse Assistant) were busy with a morning routine.On 10/22/2025 at 12:44 PM V7 (Staffing Coordinator) said, I make all schedules. The smoking room is monitored by different staff from different specialties. I make schedule daily that consists of extra staff. From Monday to Friday, there is one person per shift. V8 (Transportation Coordinator) is assigned to monitor the smoking-room Monday-Friday 6:00 AM - 5:00 PM. When V8 is busy with coordinating appointments, another staff member replaces her. V8 was monitoring yesterday (10/21/2025), at the time of the incident. After 5:00 PM, CNAs supervise the smoking room in two-hour intervals. On weekends there is regular staff who is assigned to monitor the smoking room, in addition to restorative aids and CNAs.On 10/22/2025 at 1:21 PM V8 (Transportation Coordinator) said, I was assigned to monitor smoking room yesterday (10/21/2025) between 6:00 AM to 5:00 PM. I monitor it for the most part unless I need a relief and that's when an available staff covers for me. I was there when an incident happened. I was helping in R3's room, right across the smoking room. I was responding to a call light when I heard commotion in the hallway, right by the smoking room. I came out immediately, asked what was going on, and noticed R1 yelling. I didn't see R2 hit R1. R2 wasn't saying anything. Other staff also responded to the commotion, so I went back to R3's room, I don't know what happened after that. I wasn't away from the monitoring desk for that long. Before I responded to the call light, R2 was lined up in the hallway to go into the smoking room. I don't remember seeing R1.On 10/23/2025 at 10:10 AM R3 utilizes electronic device to (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 10/27/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communicate due to significant aphasia. R3 typed, I didn't hear an altercation on the morning of 10/21/2025. The only time I use a call light is in the morning, afternoon, and at night when I have to have a bowel movement. V8 (Transportation Coordinator) did not respond to my call light on the morning of 10/21/2025, it was another staff.On 10/23/2025 at 10:15 AM R4 said, I was in the smoking room when the incident happened. R1 stormed into the room and was yelling There are people who want to smoke too! R2 got annoyed and got into a verbal altercation with R1. R1 and R2 left the smoking room and then I heard R1 yelling He hit me! There was no staff monitoring the smoking room when I was going in there. On 10/23/2025 at 11:17 AM V9 (Registered Nurse) said, The incident between R1 and R2 happened by the smoking room. I was administering medications, so I didn't witness it; however, I was told that R1 stormed into a smoking room, stepped out to the hallway, and got hit by R2 while in the front of the smoking room. Staff who was assigned to monitor the smoking room was responding to the call light during the incident, it happened very fast. I got called right after the incident and was told that R1, who was assigned to me that day (10/21/2025), needs medical attention. I gave R1 ice pack and pain medication, and he was sent to the hospital later that day, for further assessment. R1 called police too and the police came shortly after the incident and interviewed everyone. Immediately after the incident, 1:1 supervision was initiated to both residents to assure safety. R2 was later discharged from the facility, the discharged was initiated prior to the day of the incident and it just happened on the day of the incident.On 10/23/2025 at 12:40 PM V11 (Social Service Coordinator) said, I recently was assigned to R2 as a social worker. R2 was working with local contact agency in order to get transferred to lower level of care. R2's case worker was not being responsive, R2 felt like he should have been already transferred, so R2 came to me, and I found another long-term care facility that accepted R2. I submitted R2's referral packet on 10/16/2025, they reached back out to me, and accepted R2. R2 was discharged on 10/21/2025 coincidently to the incident.On 10/23/2025 at 1:01 PM V1 (Administrator/Abuse Prevention Coordinator) said, I was notified of an incident between R1 and R2 on the morning of 10/21/2025. I made sure first they're both safe, then I followed up with questions, ensured both residents got appropriate care, and are provided with 1:1 monitoring. I also made sure the police were notified. Shortly after, I sent an initial report. I then followed up with further interviews with residents and staff, and the investigation is continuing, and there is no final conclusion at this time. The abuse training for staff is done quarterly and as needed, for example, when there is a reportable incident. Most recent abuse training was done on 10/17/2025 due to another recent abuse incident. Per record review, progress note dated 10/21/2025 written by V9 (registered Nurse) reads in part, At around 0830, This writer was informed by staff that resident (R1) had a verbal altercation turned to physical and got hit on the right side of the face. Noted resident (R1) putting pressure on the affected area. Noted small skin tear on the upper and lower lip. Both residents (R1 & R2) were separated from each other. When asked what happened, per resident (R1), he was having a conversation with the other residents inside the smoking room. Conversation got heated and eventually turned to physical altercation. Right after the incident, resident (R1) who is alert and oriented x 3, called and reported to police what had happened. Both residents were immediately separated. Cold pack was applied on affected area. PRN Pain medicine given. Head to toe assessment done. Behavior monitoring initiated. At around 0835 police interviewed both residents separately. Per police interview, it was known that (R1) started the verbal altercation towards the other resident and ended up cursing the other resident that led the resident to hit (R1). Ordered to be sent to the ER for physical evaluation, resident (R1) refused going to ER for evaluation. Education was given and emphasized the importance of going for evaluation. (Medical Doctor) made aware and ordered to (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 10/27/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete involuntary petition the resident to LGH.Per record review, police report dated 10/21/2025 reads in part, Upon arrival, I made contact with (R1 and R2). I observed (R1) to be bleeding from his lip. (R1) related that while in the smoking room he became frustrated with (R2) smoking too much and verbal argument ensued. (R2) then struck (R1) in the face with a closed fist. (R1) related that he does not wish to sign complaints and wants to document incident only.The facility Abuse Prevention and Reporting policy last revised on 10-24-2022 reads in part, 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. Event ID: Facility ID: 145171 If continuation sheet Page 4 of 4