Health inspection·October 24, 2023

F 0580 will be re-evaluated by the wound physician during the indicated next visit . Level of Harm - Minimal harm or potential for actual harm The facility does not have documentation to show V8 was notified of R1's change in treatment of her Stage 3 pressure ulcer. Residents Affected - Few The facility's Wound Report dated October 20. 2023 showed R1 had an active sacral Stage 3 pressure ulcer identified in the facility on June 28, 2023. On October 20, 2023, at 11:48 AM, V8 (R1's Family) said she was not notified of R1's pressure ulcer until R1's care plan meeting which took place about two weeks ago. V8 continued to say the facility informed her at the care plan meeting R1's pressure ulcer was present since July. V8 said nobody from the facility contacted V8 regarding R1's pressure ulcer. On October 20, 2023, 2:20 PM, V3 (Wound Care Coordinator) said she does not have documentation to show R1's family was notified when R1's pressure ulcers were identified. V3 said she should have notified R1's family when R1's wound deteriorated on August 30, 2023, and September 13, 2023. V3 continued to say V3 did not notify R1's family of the change in treatment of R1's sacral Stage 3 pressure ulcer. V3 said she should have notified R1's family of the change in treatment of R1's sacral Stage 3 pressure ulcer. On October 20, 2023, at 2:45 PM, V2 (DON/Director of Nursing) said a resident's family should be notified as soon as possible if a resident acquires a pressure ulcer while residing in the facility. V2 continued to say facility staff should be documenting in the EMR if a resident's family was notified or if an unsuccessful attempt was made to contact the family. V2 said if a resident's pressure ulcer is deteriorating, the resident's family should be notified. 2. R2's EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, breast cancer, and stage 4 pressure ulcer of the left heel. R2's MDS dated [DATE], showed R2 had severe cognitive impairment. The MDS continued to show R2 was dependent on facility staff for toilet use, personal hygiene, bed mobility, and transfers. The facility's Wound Report dated October 20, 2023, showed R2 had a left heel Stage 4 pressure ulcer identified in the facility on August 3, 2023. The facility does not have documentation to show V9 (R2's Family) was immediately notified of R2's pressure ulcer. The facility's skin evaluation form was initiated by V3 on August 3, 2023 showed R2's family was notified of R2's pressure ulcer on August 7, 2023, four days after the wound was identified on August 3, 2023. On October 20, 2023, at 1:58 PM, V3 said she notified V8 of R2's left heel pressure ulcer four days after R2's pressure ulcer was identified. V3 continued to say she usually notifies families the day after the pressure ulcer is identified. On October 23, 2023, at 1:24 PM, V4 (ADON/Assistant Director of Nursing) said V3 is responsible for notifying resident families of newly identified pressure ulcers. V4 continued to say a resident's family should be notified as soon as possible or at lease within 24 hours. V4 said the notification (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 2 of 3 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 10/24/2023 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 0580 of the family should be documented in the EMR. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Skin Care Treatment Regimen dated July 28, 2023, showed, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedures: .7. Notify the patient family/next of kin or POA (Power of Attorney) for any new sore that is identified during the course of stay at the facility . Residents Affected - Few The facility's policy titled, Notification for Change of Condition, dated July 28, 2023, showed, Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures: 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the residents legal representative or an interested family member when there is: . b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 3 of 3