Inspection·October 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placed around the resident's waist with two-finger space between the belt and resident's body.On October 15, 2025 at 4:10pm, V10 (Restorative Nurse/Licensed Practical Nurse) said that it is unsafe for a CNA (Certified Nursing Assistant) to transfer a resident using a gait belt around their own waist. V10 said that the transfer belt should be secured around the resident's waist with adequate spacing and should always be used during transfers with unsteady residents.???????????2. R3 is an [AGE] year-old female with a diagnosis's history of Dementia, Anxiety Disorder, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Abnormalities of Gait and Mobility, and Lack of Coordination, and Unsteadiness on Feet who was admitted to the facility 07/17/2024.R3's current care plans-initiated July 2024 shows R3 has Impaired mobility and ADL (Activities of Daily Living) self-care performance deficit related to dementia, depressive disorder, psychotic disturbance, diabetes mellitus, hypertension, and is hard of hearing with interventions including extensive participation from one staff for transfers, assistance from staff for standing and walking, and use of a walker for ambulation. R3's current care plans initiated in September 2024 shows she is at risk for fluctuating blood sugars; she is at high risk for falls related to dementia, depressive disorder, psychotic disturbance, diabetes mellitus, hypertension, is hard of hearing and taking medications such as hypnotic, anti-hypertensive and hypoglycemics.R3's current care plan-initiated April 2025 shows R3 may have challenges secondary to declining vision, poor hearing or poor comprehension.R3's Functional Abilities assessment dated [DATE] shows she requires partial/moderate assistance from staff for moving from a sit to stand position and walking. R3's Restorative assessment dated [DATE] shows her gait is unsteady, she requires assistance with ambulation and one person assistance with transfers, is on a walking program, assumes standing position with assistance, and is forgetful.R3's Fall Incident Report dated 09/21/2025 shows she had an unwitnessed fall, while sitting in a chair in front of her room, she is forgetful, lacks safety awareness, and has cognitive impairment.Facility Post Fall Investigation report shows on 09/21 at 6 PM R3 had a fall with injury and based on the information gathered from staff, resident, and medical records reviewed the resident attempted to stand up unassisted and lost her balance.Facility Final Incident Investigation Report dated 09/22/2025 shows R3 had an unwitnessed fall that resulted in a left arm fracture; she was last observed at 5:20 PM sitting comfortably in a chair prior to the fall, R3 returned to the facility with a left arm immobilizer and with an order for ortho follow up.On October 14, 2025 at 1:38 PM, R3 stated her left arm is real sore all the way up her arm and hurts really bad, When asked if anything happened to her arm, R3 stated she fell.On October 16, 2025 at 2:38 PM V10 (Restorative Nurse/Licensed Practical Nurse) stated R3 has a history of suddenly or randomly stepping back and falling backwards, and has been educated not to do so because it would cause her to fall.On October 20, 2025 at 10:11 AM, V19 (Family Member) stated she noticed changes in R3's walking ability months ago, it seems like she needs a walker and she had a walker in her room but it hasn't been used. V19 stated R3 seems to walk slower and lean to the side and she has spoken to all R3's nurses including V16 (Registered Nurse) and was told she would need to talk to the doctor, it might be R3's medication, R3's up all night due to sundowning and in the day time she's tired. V19 stated she told all the nurses to have the doctor to call her because she hasn't encountered them when she was at the facility and the doctor still hasn't contacted her. V19 stated R3 had another fall 10/18/2025 and is currently in the hospital. V19 stated nobody's watching R3 and she has walking issues, R3's walker is always sitting in her room, and V19 has never seen R3 using the walker while visiting her at the facility. V19 stated R3 gets up and walks around a lot and walks real slow and V19 was told by the staff at night R3 walks fast however she has never seen R3 walking fast. V19 stated R3's coordination and balance has been off for months which is why she asked about R3's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 2 of 5 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 10/20/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications. V19 stated she has asked the staff about R3 using the walker and they said we have a walker for R3 and she could use the walker. V19 stated when R3 began walking different she asked the facility what can they give R3 to assist her with walking. V19 stated R3's is also hard of hearing and does need assistance with walking or needs a better walker. On October 15, 2025 at 3:42 PM, V18 (Certified Nursing Assistant) stated R3 is confused, would sometimes sit in a chair outside her room and would stand on her own a lot.October 15, 2025 at 4:02 PM, V10 (Restorative Nurse/Licensed Practical Nurse) stated R3 needs help with walking, has an unsteady gait, is a fall risk, needs supervision and cueing, and will get up unassisted from a chair. V9 (Restorative Nurse/Licensed Practical Nurse) stated on 09/21/2025 R3 stood up, turned around, began walking lost her balance and fell. Neither V9 or V10 were aware of R3 using a walker or why it was part of her care plan.On October 20, 2025 at 12:25 PM, V8 (Assistant Director of Nursing) stated R3 did not have a walker when she fell on [DATE] and she has never seen R3 with a walker.On October 20, 2025 at 11:07 AM, V12 (Medical Director/Physician) stated if patients are high risk and have multiple falls we use bed alarm all the time unless the resident frequently removes it. V12 stated if the resident has a change in condition and refuses to use bed alarm or frequently removes it this will be noted in their records. V12 states most residents have gait instability, history of falls, memory loss, coordination problems, and are taking certain medications that put them at risk for falls and those residents may need bed alarms. V12 stated an assessment by physical and occupational therapy determines if residents are safe to use a walker as well as day to day assessments from the nurses. V12 stated R3's mental status does not allow her to remember to use the walker, and we put the walker next to the residents and always remind them to use it. V12 stated whenever the staff notices R3 is out of her room they come right away with the walker and remind her to use her walker and our staff are always available to help residents change positions. V12 stated there should be an attempt to have R3 use a walker and no reason why this can't be done.The facility's Fall Occurrence Policy received 10/15/2025 states in part: It is the policy of the facility to ensure that interventions are put in place. Those identified as high risk for falls will be provided fall interventions. Event ID: Facility ID: 145307 If continuation sheet Page 3 of 5 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 10/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received timely and adequate incontinence care and hygiene assistance.This failure applies to 4 of 4 residents (R1, R4, R5, and R6) reviewed for incontinence care.The findings include:1. R1 is a [AGE] year-old male who was admitted to facility on September 18, 2023.R1's face sheet includes the following diagnoses: : bilateral osteoarthritis of the knee, strabismic amblyopia, cataracts, difficulty walking, muscle wasting, gait and mobility abnormalities, dysphagia, diabetes mellitus, protein calorie malnutrition, benign prostatic hyperplasia, dementia with agitation, sleep apnea, repeated falls, gout, atherosclerotic heart disease, hyperparathyroidism, gastroesophageal reflux, post-traumatic stress disorder, AFIB (irregular heartbeat), congestive heart failure, cardiomyopathy, hypertension, and hyperlipidemia.R1‘s MDS (Minimum Data Set) dated September 23, 2025, shows R1 is cognitively impaired and requires extensive assistance of one staff member for activities of daily living tasks.On October 14, 2025 at 11:04AM V14 (Family Member) said R1 was left soiled for prolonged periods of time, and on September 25, 2025, they complained R1 had feces on his arms, hands, and under his fingernails and was not properly cleaned. V14 said that staff failed to promptly provide hygiene assistance for R1. V14 said that she informed the nurse and aide on duty as well as administrator at the time of this occurred.Review of grievances obtained on October 14, 2025, did not notate occurrence.2. R4 is a [AGE] year-old male who was admitted to facility on March 10, 2025.R4s face sheet includes the following diagnoses: Osteoarthritis, benign prostatic hyperplasia, bilateral knee stiffness, frequent falls, cardiac murmur, abnormal gait, and spondylosis.R5s current care plan dated August 15, 2025, shows a potential for skin integrity impairment due to incontinence of bowel and bladder and requires staff assistance for incontinence care.R5's MDS (Minimum Data Set) section C dated August 15, 2025 shows R4 is cognitively intact.On October 14, 2025 at 11:17 AM, R4 was lying in bed alert and oriented, wearing a hospital gown and watching television. R4's bed sheet and transfer pad had a large dark yellow ring on their surface, and a foul odor was present in the room. R4 said he had not been changed since the previous night and no aide had been in yet that morning. A green bag filled with soiled linen and a clear white bag containing soiled briefs were lying on the floor near the bed.On October 14, 2025 at 11:20 AM, V3(Certified Nurse Assistant) and V4(Certified Nurse Assistant) entered R4's room to provide care. V3 stated that this was her first time doing rounds on the unit and that she had not changed R4 during her shift, and assumed R4 was last changed around 5:00 AM by the overnight shift. V4 stated rounds are typically completed after breakfast and that if no one is available, CNAs (Certified Nursing Assistant) proceed to other duties such as showers.3. R5 is an [AGE] year-old female who was admitted to facility on May 04, 2021.R5's face sheet includes the following diagnoses: depression, insomnia, bilateral cataracts, presbyopia, protein calorie malnutrition, hypertension, falls, and osteoarthritis.R5's current care plan dated July 2025 shows R5 is at risk for impaired skin integrity due to incontinence. Clothes, linen, and adult brief are to be changed promptly when wet. R5's toileting care plan dated June 06, 2021, shows that R5 requires the assistance of one to two staff members for incontinence care and toileting needs.On October 14, 2025 at 11:50 AM, R5 stated that during the day shift on October 13, 2025, she had to wait approximately six hours before being changed. R5 stated she was soiled with feces and had informed her assigned CNA (Certified Nursing Assistant), who never returned, and she was ultimately changed by the evening CNA. R5 reported that she had not yet been checked or changed by the day shift and had last received care from the overnight shift at 5:00 AM. R5 reported that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145307 If continuation sheet Page 4 of 5 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 10/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete needed to be changed. 4. R6 is an [AGE] year-old female who was admitted to facility on December 12, 2021. R6's face sheet includes the following diagnoses: atrial fibrillation, anxiety, overactive bladder, anemia, hypothyroidism, hypertension, and congestive heart failure. R6's current care plan dated February 10, 2024, shows a risk for skin impairment with a need for staff assistance for incontinence care. On October 14, 2025 at 12:10 PM, R6 was in bed with a meal tray next to her and a foul odor was present in her room. V3 (Certified Nursing Assistant) provided care and discovered that R6's adult brief was saturated with urine and feces. V3 said R6 had not been checked or changed prior to meals and that this was her first round of the day. V3 said she believed R6 was last changed around 5:00 AM by the overnight CNA. On October 15, 2025 at 1:11 PM, V6 (Certified Nursing Assistant) stated she was not present during the incident with R1 but confirmed that facility protocol requires residents to be checked and changed every two hours and before and after meals.On October 15, 2025 at 2:15 PM, V2 (Director of Nursing) stated that CNAs are expected to check and change residents at least every two hours and before and after meals. V2 said all CNAs receive orientation, competence, and computer training upon hire.The facility's General Care Policy (dated June 30, 2025) states: The facility will provide care to meet each resident's physical and psychosocial needs.The facility's Incontinence and Perineal Care Policy (dated June 30, 2025) states: Do rounds at least every two hours to check for incontinence during shift Provide perineal care to ensure cleanliness, comfort, and infection prevention. Event ID: Facility ID: 145307 If continuation sheet Page 5 of 5