Inspection·October 27, 2022

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that a resident who required assistance in mobility and transfer was transferred from her bed to chair. Residents Affected - Few This applies to one of one residents (R66) reviewed for mobility and transfer in the sample of 26. The findings include: R66 was admitted to the facility on [DATE] according to her face sheet. R66's diagnoses included multiple sclerosis, hereditary spastic paraplegia, low back pain, hypertension, muscle wasting and atrophy in both thighs, lower legs, ankles and feet. R66 most recent minimum data set (MDS) dated [DATE] documented R66 was cognitively intact, and required extensive assistance of of two staff for mobility and transfer. On October 24, 2022 at 12:45 PM, R66 was in bed, in hospital-type gown watching television, with digital device and other personal items within reach. R66 was noted cooperative, alert and oriented. R66 confirmed she did not have a room mate, and it was noted there was no chair or wheel chair in the room. R66 reported she was admitted to the facility for therapy which she received to the completion of insurance coverage several months ago. R66 stated she has not been out of the bed since her therapy was completed. R66 stated she received the diagnosis of multiple sclerosis at age [AGE], and that she is now [AGE] years old. On October 26, 2022 at 10:40AM, R66 stated R66 would like to get out of bed, but the staff does not get her out of bed. R66 stated R66 has not been out of the bed, and staff provides her care and meals while she is in bed. R66 stated R66 would prefer to get up in a chair, for 45 minutes to an hour, and that she believes she could not tolerate being up in the chair all day due to back pain. On October 26, 2022 at 11:15 AM, V2 (Director of Nursing/DON) stated , (R66) is supposed to be getting up out of bed. We encourage residents to get up. She would get up with assist of staff. V2 stated that there is always staff available to get the residents up, and added that the nurse managers assist if needed. On October 26, 2022 at 11:50AM, V11 (Nurse Practitioner) reported that he visits R66 monthly, and that his most recent visit was September 20, 2022. V11 stated that R66 is in bed during his visits. V11 noted R66 has a diagnosis of multiple sclerosis. V11 explained that a concern of R66 not getting out of bed, is that not getting out of bed causes, deconditioning among other issues. V11 stated R66, .should be out of bed as tolerated beginning with 30-60 minutes at at time, and increasing as possible. R66's care plan showed the focus problem initialed February 26, 2022, ADL Self Care performance deficit and Impaired Mobility An intervention intervention initiated June 3, 2022 documented, Transfer: (R66) requires total assistance with transfers x2 staff using a (mechanical) lift. On October 26, 2022 at 12:45PM, V9 (Restorative Nurse) stated R66 is on a restorative program for AROM (active range of motion), PROM (passive range of motion) and bed mobility. V9 provided the electronic medical record (EMR) documentation of the restorative charting for the period October 20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 2 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete through October 26, 2022. The documentation showed one 15-minute period of AROM on the previous afternoon shift, and no other AROM was recorded. No charting was recorded for PROM or bed mobility during that same reviewed period. The facility's policy, Restorative Nursing Program dated July 28, 2022 documented, in part, 2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided, and 6. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, cnas, and/or restorative aides. Event ID: Facility ID: 145307 If continuation sheet Page 3 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two residents who required assistance with grooming and personal hygiene received staff assistance, including shaving and rendering nail care. Residents Affected - Few This applies to 2 of 26 resident (R25, R43) reviewed for activities of daily living in the sample of 26. The findings include: 1. R25 was admitted to the facility August 26, 2021 according to her face sheet. R25's diagnoses included hypertension,anxiety disorder, diabetes, chronic kidney disease, COPD and depressive episodes according to her physician's order sheet. R25's Minimum Data Set assessment (MDS) dated [DATE] documented R25 has severe cognitive impairment, and required extensive assistance of one staff for personal hygiene. On October 25, 2022 at 10:45 AM, during wound care rendered by V4 (Wound Care Nurse) R25's fingernails on both hands were long with a brown substance under the nails. V4 also noted R25's fingernails and confirmed they were long and dirty and should be trimmed. R25 agreed and reported she wanted her nails cut, and that the staff has to cut them for her. On October 26, 2022 at 10:45 AM, V4 explained that nail care should be done on shower days. V4 stated that resident's showers are scheduled for 3 times per week, and provided the unit shower schedule. The shower schedule documented R25 was scheduled for showers on Tuesdays, Thursdays, and Saturdays the on day shift. R25's care plan documented a focus problem initiated September 16, 2021 shows R25 has an ADL Self Care Performance deficit with an intervention (initiated on the same date) (R25) requires 1 staff participation with personal hygiene . 2. R43's EMR included diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, cerebral infarction due to embolism of left middle cerebral artery, dysphagia following other cerebrovascular disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R43's quarterly MDS dated [DATE] included that R43 requires total dependence of two persons physical assist for personal hygiene. On 10/24/22 at 12:06 PM, R43 was lying in bed and had stubbles of facial hair. R43 was alert and responded to queries. When asked, R43 stated I want to shave. R43's hands appeared contracted. On 10/25/22 at 12:42 PM, R43 was in bed and still had facial hair and this information was relayed to V5 (Certified Nursing Assistant). R39 (R43's roommate) who was lying in the next bed stated They don't do nothing for people here. You have to ask and they say they will be back and don't. I can do it myself but he (R43) can't. On 10/26/22 at 11:50 AM, R43 was in bed and still had facial hair. This information was relayed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 4 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0677 V8 (CNA) who was at bedside. Level of Harm - Minimal harm or potential for actual harm R43's care plan initiated 06/07/22 for ADL care included R43 requires total staff participation [times one-two] with personal hygiene and oral care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 5 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to put heel protector boots on residents with a history of pressure sores and with a physician order for the same. Residents Affected - Few This applies to 2 of 7 residents (R43 and R46) reviewed for pressure sores in the sample of 26. The findings include: 1. R43's EMR (electronic medical records) included diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, cerebral infarction due to embolism of left middle cerebral artery, dysphagia following other cerebrovascular disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R43's quarterly MDS (minimum data set) dated 9/14/22 included that R43 requires total dependence of 2 persons physical assist for bed mobility. R43's POS (Physician Order Sheet) included heel protector boots (status active, revised 7/20/2022). On 10/24/22 at 12:09 PM, R43 was lying in bed with left leg tucked under thigh. R43 had no heel protectors on. V10 CNA (Certified Nursing Assistant) who came into the room stated His left leg is contracted. He likes to sleep like that. On 10/25/22 at 12:48 PM, R43 was lying in bed with legs tucked underneath the bed sheet covers. When V5 (CNA), who was at bedside, removed bed sheet cover, R43 had no heel protectors on. On 10/25/22 at 01:08 PM, V4 (Wound nurse/Licensed Practical Nurse) stated that R43's wounds have resolved. R43 stated He has an order for heel protector boots for wound prevention. On 10/26/22 at 11:50 AM, R43 was lying in bed with the right leg in a heel protector boot. R43's left leg was covered under a bed sheet cover. On request, V8 (CNA) who was present at bedside, removed the bed sheet cover and R43's left leg was seen tucked underneath right thigh. When V8 straightened R43's left leg and checked R43's left foot, there was redness on the left side of the foot. 2. R46's EMR included diagnoses of unspecified lack of coordination, repeated falls, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, infection following a procedure, superficial incision surgical site, subsequent encounter, osteoarthritis of knee, unspecified. R46's quarterly MDS dated [DATE], showed that R46 needs extensive two person physical assist with bed mobility. R46's POS included an order for heel protector boots (status active, revised on 10/7/2022) On 10/24/22 at 12:19 PM, R46 stated I had surgery on my buttocks and its well now. Its healed all the way up. I also had one (wound) on my heel and they healed that one up too. R46 was not wearing heel protectors. On 10/25/22 at 01:48 PM, R46 lying in bed with both feet in long orange colored socks. R46's had a pillow tucked under the back of her thighs and both feet were touching the bed sheet at the heel. R46 did not have heel protectors on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 6 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/25/22 at 01:57 PM, V4 stated that R46 is supposed to wear heel protector boots as she has had a history of wounds and also for protection. On 10/26/22 at 11:40 AM, R46 was lying in bed with pillows tucked beneath back of thigh with her heels touching the bed sheets. R46 was wearing long orange colored socks. Two green colored heel protector boots were seen on a wheelchair at side of R46's bed. On request, when V8 (CNA) who was present at bedside, removed R46's socks, it was noted to have darkened colored skin under her feet. R46 was wincing when this area was touched and V8 stated that the skin under the foot is very thin. Event ID: Facility ID: 145307 If continuation sheet Page 7 of 8 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 145307 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Lagrange Park, The 701 North Lagrange Road LA Grange Park, IL 60526 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide instruction and personal protective equipment for a family member of a resident in isolation. Residents Affected - Few This applies to 1 of 5 residents (R76) reviewed for Transmission Based Precautions in the total sample of 26. The findings are: On 10/24/2022 at 11:16 AM, V17 (R76's family member) was sitting in the room with R76 who was in the bed. V17 was wearing a disposable mask and a face shield but no gown and no gloves. V17 and R76 agreed that no one had told her she should wear the gown but she was wearing a mask because R76 had been on precautions for possible COVID earlier in the stay in the facility. On 10/24/2022 at 11:16 AM, R76's door had signs showing isolation for contact and droplet precautions including instruction to wear a gown and gloves for contact with the resident. On 10/24/2022 at 11:26 AM, V6 (Registered Nurse) stated R76 was no longer on droplet precaution, only contact precaution and the sign was left inadvertently. V6 stated R76 was on precaution for ESBL (extended spectrum beta lactamase) infection and should only be on contact precautions. The facility medical record for R76 shows a laboratory report for a urine culture collected on 10/9/22 and reported 10/14/22; the report shows the urine positive for CRE (carbapenem resistant Enterobacteriaceae, Klebsiella species). An order was added to the POS (physicians order sheets) on 10/25/2022 and signed by V2 (Assistant Director of Nursing) for contact isolation for ESBL/CRE. The facility's Infection Prevention and Control policy dated 07/28/2022 showed Contact Precautions included the use of a gown and gloves for all interactions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 8 of 8