Health inspection·May 23, 2025

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 provide nail care to residents who require assistance. This applies to 3 of 3 residents (R1, R81, and R86) reviewed for activities of daily living (ADL) care in a sample of 33. Residents Affected - Few The findings include: 1. R81 is a [AGE] year-old male with severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R81 is dependent on personal hygiene. On 05/20/25 at 01:44 PM, R81 was on his bed and had long nails with a brownish substance accumulated underneath nails, with a left contracted hand and right partially contracted hand. On 05/20/25 at 01:50 PM, V27 LPN (Licensed Practical Nurse) stated CNAs (Certified Nursing Assistants) or activity aides should trim residents' nails and that R81's long nails with contracted left hand can cause a palm ulcer. R81's ADL care plan documented performance deficit and impaired ability with dressing and grooming, such as unable to complete tasks with personal hygiene. The ADL care plan interventions include total staff participation and with personal hygiene 2. R1 is a [AGE] year-old female with mild cognition impairment as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R1 requires partial/moderate assistance to personal care. On 05/20/25 at 01:59 PM, R1 had a broken nail approximately 6 millimeters (mm) long hanging from the left point fingertip. All of R1's other fingers had long dirty nails. On 05/20/25 at 2:02 PM, V23 (Registered Nurse/RN) stated that residents should get nail trimming and grooming on shower days. R1's care plan documents that R1 was care planned for extensive care needs and requires the support/services of the long-term care setting with intervention including the facility will provide care to establish the resident to function at their most practical level. 3. R86 is an [AGE] year-old male with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R86 requires partial/moderate assistance to personal hygiene. On 05/20/25 at 01:46 PM, R86 was on his bed and his left hand nails were long and he had a broken Page 1 of 20 145339 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0677 jagged nail on his left fourth finger. Level of Harm - Minimal harm or potential for actual harm R86's ADL care plan documented performance deficit and impaired ability with dressing and grooming, such as unable to complete task with personal hygiene. Residents Affected - Few On 05/21/25 at 10:17 AM, V3 (Director of Nursing) stated the CNAs are supposed to provide nail trimming and grooming on shower days. The facility's Nail Care policy (revised 8/16/24) showed Nursing staff shall check the residents for Nail Care which includes cleaning and regular trimming 145339 Page 2 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to assess and obtain treatment orders for a resident with a laceration. This applies to 1 out of 1 resident (R340) reviewed for wound treatments in a sample of 33. Residents Affected - Few The findings include: On 5/20/2025 at 10:35 AM, R340 was noted with a wrapped gauze dressing on right lower leg. The gauze was brown in color with dried blood stains and was unraveling. R340 said on 5/18/2025, her right leg caught on her wheelchair and she sustained a laceration. R340 said the wound was bleeding too much that she was sent to a local hospital where she got eleven stitches. R340 said no staff has come to assess her wound and the dressing on her wound has not been changed since she returned from the hospital. On 5/21/2025 (three days after R340 returned from the hospital) at 8:57 AM, R340's right leg wound dressing still had the same dried blood stains and the gauze was still unraveling. On 5/21/2025 at 9:05 AM, V15 (LPN- Licensed Practical Nurse) reviewed R340's POS (Physician Order Sheet) and said she cannot find any treatment orders for R340's right lower leg wound. On 5/21/2025 at 10:15 AM, V6 (Wound Care Director) reviewed R340's POS and said she could not find wound care orders for R340's leg wound. V6 said she has not assessed R340's wound since she came back from the hospital. On 5/22/2025 at 10:07 AM, V6 said the receiving nurse should have verified and carried out R340's wound care orders. V6 said she should have assessed R340's wound as soon as she came back to the facility. V6 stated that prompt assessment and obtaining and carrying out wound care orders should be done to avoid delay in care. On 5/22/2025 at 12:10 PM, V21 (Treatment Nurse) said she changed R340's wound dressing on 5/21/2025. V21 stated there were no wound orders transcribed into R340's POS, and she said she got the treatment orders from R340's hospital records. V21 said she worked on 5/18/2025 but was not able to assess R340 when she came back to the facility. Facility's Policy on Skin Care Regimen and Treatment Formulary (reviewed 3/24/2025) documents Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown . 145339 Page 3 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow treatment orders as prescribed for residents with pressure wounds. This applies to 2 of 4 residents (R128 and R8) reviewed for pressure injuries in a sample of 33. Residents Affected - Few The findings include: 1. On 5/21/2025 at 9:00 AM, V6 Wound Care Nurse (WCN) said R8 had a present-on-admission stage 4 pressure injury to her sacrum. V7 (WC Aide) assisted V6 with changing R8's sacral wound dressing. V6 removed a white bordered gauze dressing with moderate amount of serous sanguineous drainage (no other dressing was present). V6 said R8's ordered treatment included collagen (tissue growth stimulator) and calcium alginate (absorbent) dressings. V6 said R8's wound had slough tissue and undermining approximately from 5 o'clock through 8 o'clock. V6 said she was unsure why R8's ordered treatment dressings were not followed. V34's (WC NP/Nurse Practictioner) Wound Assessment Report dated 5/16/2025 said R8's stage 4 sacrum wound status showed delayed wound closure. The report said the wound measured 4.5 cm x 2.0 cm x 0.5 cm with an undermining of 0.3 cm from 5 o'clock to 7 o'clock. The report continued to say the wound had 100% granular tissue with moderate serosanguineous drainage. V34's treatment order said to apply collagen and calcium alginate with a bordered gauze dressing three times per week and PRN (as necessary). R8's Order Summary Report dated 5/22/2025 had active scheduled and PRN orders initiated on 5/09/2025 for her sacrum, Treatment: Sacrum: Cleanse w/ wc, apply collagen and calcium alginate, cover with bordered gauze. R8's skin integrity care plan for her sacrum initiated on 8/09/2025 said Follow facility protocols for treatment of injury (see treatment orders)/POS. 2. On 5/20/2025 at 10:30 AM, R128 said he acquired a wound to his right heel from the pressure of his feet being up against the footboard of his bed. On 5/21/2025 at 8:45 AM, V6 (Wound Care Nurse/WCN) said R128 had a facility-acquired unstageable pressure injury to his right heel. V7 (Wound Care Aide) assisted V6 (WCN) with changing R128's right heel dressing. V6 removed R128's dressing and said the wound had necrotic tissue. V6 cleaned R128's wound and applied a pre-made dressing. V6 said R128's applied dressing was medihoney ointment then an adaptic (non-adherent) dressing with an ABD pad and secured with kerlix. V6 said V34 (WC Nurse Practitioner/NP) managed R128's right heel pressure injury weekly. R128's Order Summary Report dated 5/22/2025 had an active order initiated on 5/14/2025 for his right heel, Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to R Heel topically every day shift every Wed, Fri, Sun for wound Cleanser w/, apply medihoney w/ calcium alginate and ABD and rolled gauze. V34's (WC NP) Wound Assessment Report dated 5/16/2025 said R128's right heel wound was full-thickness and measured 2.5 cm (centimeters) x 3.0 cm x 1.0 cm. The report continued to say the wound had exposed subcutaneous tissue with 20% granulation and 80% slough tissue (0 % necrotic) with scant serosanguineous drainage. V34's 5/16/25 treatment order said to apply Medical grade honey with an ABD pad and rolled gauze three times per week and PRN (as needed). 145339 Page 4 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R128's TAR (Treatment Administration Record) for 5/01/2025-5/31/2025 did not show V34's (WC NP) order from 5/16/2025 was implemented. On 5/22/2025 at 9:50 AM, V6 (WCN) said she applied an adaptic dressing to R128's right heel on 5/21/2025 because she believed that was the order prescribed by V34 (WC NP) on 5/16/2025. V6 (WCN) said the wound care team was responsible for reviewing and transcribing V34's (WC NP) wound care treatment orders. V6 continued to say nurses were expected to follow treatment orders as prescribed to promote wound healing, prevent complications, and assess if prescribed treatment orders were effective. The facility's policy titled Skin Care Regimen and Treatment Formulary dated 3/24/2025 said It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown .2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily .8. Stage III and IV pressure injuries may be referred to wound care specialist (either an advanced nurse practitioner or physician specializing in wound care and ostomy management) for further clinical and treatment consultation in accordance with facility protocol and standard of care. 145339 Page 5 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure a resident's wheelchair was in safe repair to prevent injuries. The failure resulted in R340 sustaining an L shaped laceration on her right lower leg when she bumped her right leg and scraped it on the uncapped right front wheel connector. R340 was sent to the hospital and received 11 sutures for the laceration on her right leg. This applies to 1 out of 1 (R340) resident reviewed for accidents in the sample of 33. The findings include: On 5/20/2025 at 10:36 AM, R340 was in her room with a soiled dressing on her right lower leg. R340 said on 5/18/2025 at around 5:00 AM, she was in the bathroom and when she was transferring from her wheelchair to the toilet, the skin on her right leg caught on the uncapped right front wheel connector of her wheelchair. She said she was bleeding so much that she was sent to the hospital and she has 11 stitches on her right leg. R340's Progress Notes from the Emergency Department of the local hospital dated 5/18/2025 documents R340 said she sustained laceration because her leg got caught on her wheelchair. Length of laceration is 7 cm (centimeters). Wound was closed with eleven stitches. On 5/21/2025 and 5/22/2025, the right front wheel connector on R340's wheelchair was uncapped. On 5/22/2025 at 1:21 PM, V22 (LPN-Licensed Practical Nurse) said around 5:00 AM, he noticed R340's call light was on. V22 stated he noted blood. V22 said R340 told him she bumped into her wheelchair from transferring from toilet to wheelchair. V22 said R340's wound was gaping and bleeding profusely and he immediately provided wound treatment. V22 said R340's wheelchair had nothing sticking out but said he did not notice the uncapped right front wheel connector of R340's wheelchair. On 5/22/2025 at 9:45 AM, V19 (Rehab Director) checked R340's wheelchair. R340 told V19 that she got caught on the uncapped right front wheel connector, was sent to the hospital and got 11 stitches. V19 said the wheelchair's part where resident was claiming she hit her leg on was supposed to be capped. On 5/22/2025 at 9:57 AM, V20 (NP-Nurse Practitioner) said the uncapped right front wheel connector can be the reason of the laceration because she hit her leg on it. She said R340 might not have the laceration if the wheelchair was kept in good and safe repair. On 5/22/2025 at 1:11 PM, V3 (DON-Director of Nursing) said she expects her staff to inform her of any medical equipment in disrepair including the wheelchair. She said medical equipment should be in good, safe repair to prevent injuries. Facility's Maintenance Policy adopted 1/2/16 and reviewed and revised on 8/16/24 documents it is the facility's policy to maintain equipment and the building environment. 145339 Page 6 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with indwelling urinary catheters in a manner to prevent infection. This applies to 2 of 2 residents (R441 and R58) reviewed for urinary catheters. The findings include: 1. On 5/20/25 at 12:04 PM, R441 was noted with indwelling urinary catheter draining cloudy yellow urine. R441 said the staff in the facility empty the urine from his drainage bag, but they don't ever clean his urinary catheter tubing. R441 said only the doctor at the doctor's office cleaned the tubing. On 5/22/25 surveyor asked to observe catheter care and at 10:11 AM, V11 and V12 (Restorative Aides) were observed providing catheter care for R441. Prior to the start of catheter care, R441's catheter drainage bag was noted to be hanging on the lower side rail of R441's bed, with the bottom of the bag resting on the floor. Prior to starting urinary catheter care, V11 and V12 noted that R441 had a bowel movement. V11 provided incontinence care first. While R441 was lying on his left side, she cleaned his stool with a soapy washcloth, then used a large dry towel to wipe between his buttocks and pat him dry. V11 then used that same large towel that she just used to wipe R441's buttocks to drape over him while V12 went into the hall to get more supplies. When V11 and V12 turned R441 onto his right side, V12 removed the dirty towel/brief/pad from under R441 and placed them on a clean area of the bed, by the resident's feet. V11 then unclipped the urinary catheter drainage bag from the bed frame and placed it on R441's bed. V11 then proceeded to perform catheter care, but she did not clean the top 1 inch of the catheter tubing by the insertion site/urethra. V11 then touched R441's sheets and his side rail buttons to raise the head of his bed back up, with the same soiled gloves she just used to touch R441's perineal area and catheter tubing. R441's Care Plan initiated 4/7/25 shows he has an indwelling urinary catheter due to neurogenic bladder and interventions include to perform catheter care every shift and as needed. Care Plan dated 4/8/25 shows R441 was on antibiotic therapy related to UTI (Urinary Tract Infection). R441's POS (Physician Order Summary) shows an order dated 4/7/25 to perform catheter care every shift. On 5/22/25 at 10:11 AM, V11 and V12 (Restorative Aides) said catheter care is done once daily as part of morning care. V11 and V12 said urinary catheter care should be documented in the EMR (Electronic Medical Record) under tasks. V11 and V12 said urinary catheter care is usually done by either the CNAs (Certified Nurse Assistants) or the Restorative Aides. On 5/22/25 at 11:30 AM, neither R58 nor R441 had a task in their EMR for performing catheter care. No documentation in either chart was found for catheter care being performed every shift. On 5/22/25 at 12:58 PM, V3 (DON/Director of Nursing) said catheter care should be done every shift. V3 said the urinary catheter drainage bag should never touch the floor because of the risk of cross contamination and for infection control purposes. V3 said the entire urinary catheter tubing should be cleaned, including the first inch by the insertion site. V3 said dirty linens and briefs should not be placed on the resident's bed because of the risk of cross contamination. V3 said the urinary catheter drainage bag should never be placed on the resident's bed because of the risk of back flow of urine into the bladder which could lead to UTI. V3 said the staff should change their gloves and perform hand hygiene after performing catheter care and before touching clean linens or the side rails, because of the risk of cross contamination from the soiled gloves. 145339 Page 7 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 5/20/25 at 1:48 PM, R58's indwelling urinary catheter bag was hanging on his wheelchair armrest, above the level of his bladder, with urine back-flowing into the bladder. R58 said he had been transported to the hospital a few times with UTIs (Urinary Tract Infections) and they give him antibiotics in the facility on a regular basis. R58 said the facility staff do not regularly clean his catheter tubing. On 5/22/25 surveyor asked to observe catheter care and at 10:39 AM, V11 and V12 (Restorative Aides) were observed providing catheter care for R58. Prior to starting, R58's urinary catheter drainage bag was clipped to the low part of bed frame with the lower part of the bag resting on the floor. V12 lifted the drainage bag up and placed in on the resident's bed while catheter care was performed. After V11 and V12 completed catheter care, V11 raised R58's urinary catheter drainage bag up above his body while he was lying flat in bed, and threaded the drainage bag through the leg of the new pull up brief. When V11 raised the drainage bag up, urine backflow could be visualized moving towards the resident's bladder. On 5/22/25 at 11:00 AM, after catheter care was completed, R58 was asked how often the staff clean his catheter tubing as they had just done. R58 said, Not often, maybe never. R58 said sometimes the nurse will flush his catheter, but they don't clean the tubing like they just did. R58's Care Plan dated 1/10/24 says he has an indwelling urinary catheter due to diagnosis of obstructive and reflux uropathy. Interventions include position catheter drainage bag and tubing below the level of the bladder. Another Care Plan dated 1/10/24 says R58 has potential for infection related to history of urinary tract infections. Interventions include initiate proper precautions per facility protocol. The facility's policy titled, Urinary Catheter Care last revised 8/19/24 states, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident . General Guidelines .b. Maintaining Unobstructed Urine Flow: .iii. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control: 2.b. Be sure the catheter tubing and drainage bag are kept off the floor .Steps in the Procedure .17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward . Documentation: 1. The date and time that catheter care was given . 145339 Page 8 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0692 Provide enough food/fluids to maintain a resident's health. 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 process reccommendations for and then provide residents their dietary nutritional supplements. This applies to 3 of 3 residents (R57, R4, and R8) reviewed for nutrition in a sample of 33. Residents Affected - Few The findings include: 1. On 5/21/2025 at 12:10 PM, V11 (Restorative Aide) was feeding R57 in the dining room. R57 appeared thin. At 12:40 PM, V11 said she finished feeding R57, and R57 had consumed approximately less than 20% of her lunch. On 5/22/2025 at 12:20 PM, R57 was in bed for lunch. V24 (Agency Certified Nurse Assistant/CNA) said she tried to feed R57 her lunch, but she refused. V24 said she would ask the nurse for R57's prescribed supplement drink. On 5/22/2025 at 11:30 AM, V23 (Registered Nurse/RN) reviewed R57's orders. V23 said R57 had an order to receive 237 ml (milliliters) of her nutritional supplement twice a day. On 5/22/2025 at 1:00 PM, V26 (Registered Dietician/RD) said R57 was being monitored weekly for her significant weight loss. V26 said she reviewed R57's weight and nutritional intake on 5/05/2025 and believed she made new recommendations to increase R57's nutritional supplement drink amount. V26 said she enters a progress note in the resident's EMR (Electronic Medical Record) and e-mails V3 (Director of Nursing/DON) her weekly dietary log recommendations. On 5/22/2025 at 1:40 PM, V3 (DON) said she reviews and carries out V26's (RD) weekly dietary recommendations to ensure nutritional interventions are provided to residents to prevent weight loss. V3 said she received R57's new dietary recommendation on 5/07/2025 to increase her nutritional supplement to three times a day. R57's EMR showed R57's weights decreased from 112 pounds on 3/3/2025 to 103 pounds on 5/12/2025 to 100 pounds on 5/22/2025. V26's (RD) 5/5/2025 progress note titled Sig WT Change Note: -5.2% in 30 days showed R57 continued to trigger for significant weight loss. The note said V26 recommended to increase Ensure to TID (three times a day) to provide additional support. Facility's document titled RD Recommendations & Tracking Form log dated 5/07/2025 showed R57's recommendation to increase her nutritional supplement to three times a day was not implemented. R57's Order Summary Report dated 5/22/2025 showed an active order initiated on 2/11/2025 for Ensure two times a day for supplement Give 237 mL and drink by mouth. 2. On 5/20/2025 at 12:20 PM, R4 was in bed eating his lunch. R4's lunch ticket said he was to receive a nutritional frozen dessert supplement with the meal. R4's served lunch did not include any nutritional supplements. On 5/22/2025 at 12:25 PM, V24 (Agency CNA) served R4's lunch tray. No nutritional supplements were 145339 Page 9 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0692 present on R4's served tray. Level of Harm - Minimal harm or potential for actual harm On 5/22/2025 at 12:25 PM, V25 (Dietary Manager) said residents should be served their nutritional frozen dessert or alternative might shake supplements as indicated in their meal ticket as part of their ordered weight management interventions. V25 said the residents' ordered nutritional frozen and shake supplements were provided by the kitchen. V25 said the nutritional supplements should be served with the residents' meal trays when being prepared in the kitchen line before being delivered to the units. Residents Affected - Few R4's Dietary Evaluation assessment dated [DATE] said R4 was identified to have significant weight loss and was malnourished. The assessment showed R4 was to continue to receive his nutritional supplements including a Magic Cup daily (nutritional frozen dessert). 3. On 5/20/2025 at 12:20 PM, R8 was in bed eating her lunch. R8's lunch ticket said she was to receive a nutritional frozen dessert supplement with the meal. R8's served lunch did not have a nutritional supplement. On 5/21/2025 at 12:35 PM, R8 was served her lunch tray. R8's was not served her nutritional dessert nor shake supplement as indicated in her lunch ticket. R8's Dietary Evaluation assessment dated [DATE] said R8's weight was suboptimal for her age and she had increased nutritional needs due to her stage 4 sacral pressure injury. The assessment said R8 was to continue to receive her supplements, including her Mighty Shake (nutritional shake supplement). On 5/22/2025 at 3:00 PM, V1 (Administrator) and V8 (Regional Nurse Consultant) said the facility did not have a policy regarding nutrition or nutritional supplements. 145339 Page 10 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to coordinate transportation procedure/activities to avoid several missed appointments to residents. This applies to 3 of 3 residents (R52, R91, R127) reviewed for outside appointments and transportation in a sample of 33. Residents Affected - Few The findings include: 1. R91 is a [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 5/21/25 at 11:15 AM, during resident groups, R91 stated she went for an ortho appointment yesterday and couldn't see the Ortho physician as the facility didn't send the proper paperwork. R91 stated she needed to go back again. R91 stated the nurse didn't know about R91's appointment to prepare the paperwork for it. R91 blamed V18 (Transportation Coordinator) for not communicating with nurses. R91 stated it was not the first time she missed my appointments. R91's nursing progress note dated 5/21/25 documents that R91 had an ortho appointment yesterday and was unable to be seen so it needed to be rescheduled. A review of the general progress note dated 5/6/25 documented that R91 had two scheduled appointments on 5/6/25 and was unable to attend due to transportation issues. On 05/21/25 at 01:59 PM V15 (R91's Nurse) stated they were not notified of R91's appointment on 5/20/25. V15 stated V18 was supposed to post it on the resident's calendar, but it wasn't entered. V15 stated R91 went for an appointment without having paperwork. V15 stated this is not the first time she and other residents have missed their appointments. V15 stated if staff get a notification, they could prepare the resident for their appointments. On 05/22/25 at 11:37 AM, V18 (Transportation Scheduler) stated she set up R91's appointment and put it on the facility calendar but she did not put it in R91's electronic medical record calendar or tell the nurses. On 05/21/25 at 01:41 PM, reviewed R91's electronic medical record (EMR) with V33 (Receptionist) and no appointment details were posted in R91's EMR. V33 stated, V18 is the medical records person who also arranges transportation. The nurses prepare the paperwork for appointments after they get notification from V18. The facility presented the Appointment and transportation policy revised on 7/12/24 document: The facility will assist in arranging transportation for the resident unless the resident or the resident's responsible party will arrange the transportation themselves. 2. On 5/20/25 at 11:32 AM, R52 said in the Fall of 2024 she had problems with missed doctor's appointments due to V18 (Medical Records/Transportation Coordinator) dropping the ball. R52 said V18 had problems with setting up transportation for appointments, thus making R52 miss appointments. On 5/22/25 at 11:46 AM, V18 said R52 refused to go to 1 or 2 appointments because her insurance 145339 Page 11 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wouldn't pay for a medicar and she did not want to go by regular car. V18 said she keeps records of all scheduled and canceled appointments on paper. V18 said she does not document canceled appointments in the medical record. On 5/22/25 at 12:27 PM, V18 provided surveyor with Appointment Schedule Forms for R52's appointments scheduled on 10/15/24 and 10/22/24. Both forms say canceled at the top of them and have transportation by Medicar checked. V18 said she is not sure why the appointments were canceled, she did not record that on the forms. R52's Care Plan does not say anything about her refusal to go to doctor's appointments. R52's progress notes do not say anything about her refusal to go to doctor's appointments on 10/15/24 or 10/22/24. 3. R127's MDS dated [DATE] shows her cognition is intact. On 5/20/25 at 10:45 AM, R127 said she is worried because she needs to have an appointment to see the doctor and she had an appointment on April 28th that was canceled. R127 said the appointment was canceled because of problems with transportation and V18 did not set up an escort to go with her to her appointment. R127 said the doctor's appointment cancellation was out of her control; it was not canceled because of her or the doctor's office, it was canceled due to the poor communication of V18. R127 said V18 has not been back in to talk to her since the April 28th appointment was canceled and R127 does not know if the appointment has been rescheduled. R127 said V18 has accused her of canceling appointments in the past that she did not cancel. On 5/22/25 at 11:46 AM, V18 said R127's appointment on April 28th was canceled because R127 refused to go. V18 said R127 told her nurse that she did not feel like going. On 5/22/25 at 12:41 PM, V18 provided surveyor with R127's Appointment Schedule Form for appointment on 4/28/25. The form shows that escort is needed and has the phone number for the transportation service that was scheduled. On 5/22/25 at 1:21 PM the transportation service was called and V32 (Transport Services) said they did not have any records showing R127's name for an appointment on 4/28/25. V32 said he did not have any email or text message correspondence with V18 regarding an appointment for R127 on that date. On 5/22/25 at 1:27 PM, V18 said there is no progress note documented on 4/28/25 saying why her appointment was canceled. On 5/22/25 at 11:07 AM, V30 (LPN/Licensed Practical Nurse) said both R52 and R127 have had problems with doctor's appointments being canceled because of V18. V30 said R52's appointments were not canceled because of the doctor's office or R52, the appointments were canceled because transportation did not show up because V18 never set it up. V30 said she was R127's nurse on April 28th when her doctor's appointment was canceled. V30 said R127 was all ready to go to her appointment, but she needed an escort and V18 did not set up an escort for the appointment. V30 said transportation showed up, but there was no escort scheduled and when the escort was finally available, the transportation had left so the appointment was canceled. The facility's policy titled, Appointment and Transportation Policy last revised 7/12/24 states, Policy: When a resident requires an appointment outside the facility, the appointment will be scheduled in a timely manner as outlined below. Procedure: . 3. The facility will assist in arranging transportation for the resident . 4. Depending on the resident's medical, physical and cognitive needs and condition, the resident may require an escort while out of the facility for an appointment. If the resident has no representative, family member, friend, etc. to escort him/her during the appointment, the facility will provide one. 145339 Page 12 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications as ordered. There were 25 opportunities with 3 errors resulting in a 12% error rate. This applies to 2 of 7 residents (R127, R190) observed during the medication pass. Residents Affected - Few The findings include: 1. On 5/21/25 at 8:05 AM, V16 (RN-Registered Nurse/Agency) administered one pill of Zinc 50 MG (Milligrams) to R127. Review of R127's POS (Physician Order Sheet) shows an order of Zinc Sulfate Oral Tablet 110 MG (Milligrams)-Give 1 tablet my mouth two times a day. On 5/21/25 at 2:00 PM, surveyor went upstairs and checked V16's medication cart with her. V16 showed surveyor the house stock bottle where she pulled the Zinc from. On the bottle, it showed Zinc 50 MG. V16 stated she did not give the correct dosage. V16 said, I'm aware of the problem. That's not enough as per the doctor's orders. The doctor should have been notified to change the order. Sometimes, before the end of my shift, I will go give her another 50 MG of the Zinc tablet, but I don't document that. I know, it doesn't solve the problem because that only equals 100 MG. So, 10 MG will be missing. 2. On 5/21/25 at 8:44 AM, V17 (LPN-Licensed Practical Nurse) started administering medications to R190. V17 administered 3 capsules of Duloxetine 20 MG (total 60 mg) to R190. V17 also administered Fluticasone Propionate Salmeterol inhaler to R190. After inhaling one puff, V17 did not provide R190 water and encouragement to rinse his mouth. Review of R190's POS shows orders of: Duloxetine HCL oral capsule delayed release particles 30 MG-Give 3 capsules by mouth one time a day for depression. Give 3 capsules which equals 90 MG and Advair Diskus Aerosol Powder Breath Activated 500-50 MCG (Micrograms)/Dose (Fluticasone-Salmeterol)-1 inhalation-inhale orally every 12 hours for SOB (Shortness of Breath). On 5/21/25 at 2:30 PM, V17's medication cart was checked. V17 pulled out two different medication cards of Duloxetine for R190. One card had capsules of 20 MG and the other card had capsules of 30 mg. Surveyor told V17 that she administered the 20 MG of Duloxetine instead of the 30 MG to R190. V17 stated the 20 MG medication card should not be in the medication cart. On 5/21/25 at 2:50 PM, V3 (DON-Director of Nursing) stated nurses should follow doctor's orders and administer the correct dosage of medications. V17 also confirmed after administering steroid inhalers like Advair, the resident's mouth should be rinsed out with water to prevent yeast infections such as thrush. Facility's policy titled Physician Orders (Revised 8/16/24) shows the following: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Facility's policy titled Medication Pass (Revised 8/16/24) shows the following: 3. Inhalers: C. Rinse mouth with water afterwards. Some inhalers do not need to be rinsed with water after 145339 Page 13 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0759 Level of Harm - Minimal harm or potential for actual harm administration. Manufacturer's guidelines for Fluticasone Propionate and Salmeterol Inhalation Powder document the following: Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. Residents Affected - Few 145339 Page 14 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label residents' opened insulin pens and vials with the residents' name, opened-on, and expiration dates, and failed to remove expired medication. This applies to 7 of 8 residents (R30, R31, R48, R54, R64, R67, R189) reviewed for medications in a sample of 33. The findings include: On [DATE] at 10:54 AM, on the 2nd floor, inside V10's (LPN-Licensed Practical Nurse) medication cart, the following observations were made: 1. R48's Toujeo insulin (Glargine Pen) had no open or expiration date. R48's POS (Physician Order Set) shows an order of Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 Unit/ML (Milliliters) (Insulin Glargine)-Inject 22 units subcutaneously every 12 hours. 2. R189's Glargine insulin had no open or expiration date. R189's POS shows an order of Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine)-Inject 60 units subcutaneously two times a day. There was a Humalog Kwik pen with no resident name, also with no dates. There was a vial of Humulin R insulin with an opened on date of [DATE] with no resident name. On [DATE] at 11AM, V10 stated that all insulin pens should be labeled with the resident's name and should have an open and expiration date. On [DATE] at 11:12 AM, on the first floor, inside V15's (LPN) medication cart, the following observations were made: 3. R30's Basaglar insulin pen had no open or expiration date. R30's POS shows an order of Basaglar KwikPen 100 Unit/ML Solution pen-injector---Inject 8 units subcutaneously in the evening. 4. R64 had two insulin pens. His Lyumjev Kwik pen had no open or expiration date. His Lantus insulin pen had no open or end date. R64's POS shows orders of Lyumjev KwikPen 100 Unit/ML Solution Pen-Injector-Inject 7 units subcutaneously with meals. Hold if blood sugar is less than 100 and Lantus Solostar 100 Unit/ML Solution pen-injector---Inject 30 units subcutaneously every 12 hours for hyperglycemia. Hold insulin if blood sugar is less than 110. 5. R54 had two vials of insulin. His Lantus insulin had no open or expiration date. His Humalog insulin had no open or expiration date. 145339 Page 15 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0761 Level of Harm - Minimal harm or potential for actual harm R54's POS shows orders of Humalog injection solution 100 Unit/ML (Insulin Lispro)-Inject 2 units subcutaneously with meals. Hold for blood sugar less than 100. Insulin Detemir 100 Units/ML-Inject 30 units subcutaneously every 12 hours. Hold if glucose level is less than 110, or if not eating. 6. R31's vial of Lantus insulin had no open or expiration date. Residents Affected - Some R31's POS shows an order of Insulin Glargine Subcutaneous Solution 100 Unit/ML-Inject 30 units subcutaneously one time a day. Hold if blood glucose is less than 100. On [DATE] at 11:18AM, V15 stated all insulins should have an open and expiration date because some are good for 28 days and some are good for 30 days. 7. On [DATE] at 9:07 AM, surveyor went to the the first floor medication room with V3 (DON-Director of Nursing). Inside the fridge, R67 had two vials of Ativan 2MG/ML that expired on [DATE] ad [DATE]. R67's current May POS does not show any orders for Ativan. On [DATE] at 9:15 AM, V3 stated, The nurse should have discarded these Ativans with another nurse because they are expired. Facility's policy titled Medication Storage, Labeling, and Disposal (Revised [DATE]) shows: Policy Statement-It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Medication labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening. 3. Insulin vials are to be discarded within 28 days after opening, except for Levemir which are to be discarded 42 days after opening. 145339 Page 16 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. On 5/21/25 at 7:55 AM, outside of R45's room, there was a sign on the door that says EBP (Enhanced Barrier Precautions). Residents Affected - Few On 5/21/25 at 8:20 AM, V15 (LPN-Licensed Practical Nurse) put on gloves and entered R45's room without putting on a gown. V15 flushed R45's g-tube (gastrostomy tube) with 30 ML (Milliliters) of water. She then administered his Enulose and Docusate Sodium through R45's g-tube. Throughout the entire medication administration, V15 did not wear a gown. On 5/21/25 at 2:45 PM, V3 (DON-Director of Nursing) stated, Nurses have to wear full PPE (Personal Protective Equipment) including a gown because (R45) is on EBP precautions. When a nurse takes care of resident's g-tube or administers meds through the g-tube, she has to wear a gown. R45's care plan shows that he is receiving gastric tube feeding due to inability to eat. He has a g-tube and therefore is at risk for infections. Another care plan shows R45 is on enhanced barrier precautions related to CRE (Carbapenem-resistant Enterobacteriaceae) (urine and rectal) and GT (Gastrostomy) status. Interventions: Ensure that gown and gloves are used during high-contact resident care activities like device care-feeding tube that provide opportunities for transfer of MDRO's (Multidrug Resistant Organism) to staff hands and clothing. Facility's policy titled Enhanced Barrier Precaution (Revised 7/26/24) shows: EBP involves the use of gown and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDRO's as well as residents with wounds and/or indwelling medical devices. Procedure: EBP will be used for any resident in the facility that has indwelling medical devices such as feeding tube. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include g.) device care: feeding tube. Based on observation, interview, and record review, the facility failed to cohort and implement transmission-based precautions for a resident with an acute GI (gastrointestinal) infection. The facility also failed to follow Enhanced-Barrier Precautions (EBP). This applies to 3 out of 5 residents (R48, R74, R45) reviewed for infection control in a sample of 33. The findings include: 1. On 5/21/2025 at 2:45 PM, V5 (Infection Preventionist/IP Nurse) said R48 started having acute diarrhea on 5/12/2025. V5 said R48's stool was collected on 5/12/2025 to screen for C. difficile (an acute contagious GI infection). V5 said R48's stool resulted positive for C. diff on 5/14/2025 and was started on Vancomycin (antibiotic) treatment. V5 confirmed the facility had other available rooms to move R74 (R48's roommate). V5 said R74 and R48 were roommates until 5/15/2025 (three days later). V5 said R48 should have been placed in contact transmission based precautions when he was suspected to have C. diff infection. V5 said R74 was at risk for infections and should have been moved immediately when R48 was suspected and confirmed to have C. diff infection. R48's care plan initiated on 5/16/2025 had a focus problem for his C-Difficile infection and said he required contact precautions. The care plan said, Maintain contact isolation precaution in accordance with Centers for Disease Control (CDC) guidelines. 145339 Page 17 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R48's Order Summary Report dated 5/21/2025 showed an order for Vancomycin HCI 25 MG/ML (milligrams/milliliters) Solution reconstituted Give 125 mg via G-Tube four times a day for C-DIFF initiated on 5/13/2025. R48's report also had an order for Strict Contact Isolation (C. Diff) initiated on 5/15/2025. R48's Lab Results Report showed his stool specimen was collected on 5/12/2025 and resulted positive for C. difficile Toxin Gene on 5/14/2025. R74's Room Transfer Notification form dated 5/15/2025 said R74 was moved to another room on 5/15/2025 at 1:00 PM. R74's care plan reviewed on 5/22/2025 said he was at risk for infections because of his multiple comorbidities. The care plan said, Initiate proper precaution per facility policy. The facility's document titled Infectious Disease Isolation Guideline & Care dated 11/08/2024 said residents with acute diarrhea and C. Diff diseases required the implementation of contact precautions. The document also said residents with C. Diff were only allowed to be cohorted with another resident with a C. Diff infection. The facility's policy titled Infection Prevention and Control dated 2/10/2025 said The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection .Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precautions .Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. Examples of infectious organisms requiring contact precautions are C. Difficile . 145339 Page 18 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement it's antibiotic stewardship program to monitor usage of prescribed antibiotics for residents. This applies to 2 out of 3 residents (R109 and R85) reviewed for antibiotic use in a sample of 33. Residents Affected - Few The findings include: 1. On 5/21/2025 at 2:15 PM, V5 (Infection Preventionist/IP Nurse) said as part of the facility's antibiotic stewardship program she reviews residents who are prescribed antibiotics, including their laboratory results, to ensure they are receiving appropriate antibiotic treatment. V5 said nurses were responsible for initiating a McGeer's assessment form when receiving orders for antibiotics. V5 continued to say she then reviews and completes the assessment forms to determine if the residents met the criteria for the use of their prescribed antibiotics. V5 said R109 was started on an antibiotic for a UTI (urinary tract infection) on 5/17/2025. V5 said R109 had an abnormal urinalysis (UA) specimen that resulted on 5/18/2025. V5 said she noted today, on 5/21/2025 (four days later) that R109's UA specimen request lab form was not checked to be analyzed for sensitivity as ordered. V5 reviewed R109's 5/17/2025 assessment and said the form was not completed to determine if R109's prescribed antibiotic was reviewed for appropriate antibiotic use. R109's McGeer Criteria for Infection assessment form reviewed on 5/21/2025 said R109 was started on Ceftriaxone intramuscular injection daily for a UTI on 5/17/2025. The form included the following microbiologic specimen organism criteria instructions needed for review, Urine specimens for culture should be processed as soon as possible. R109's form was not completed to determine if he was reviewed for appropriate antibiotic use. R109's urinalysis lab result report showed his urine specimen was collected on 5/15/2025 and the final report without a sensitivity analysis was reported to the facility on 5/18/2025. R109's Order Summary Report dated 5/21/2025 showed an active order for Ceftriaxone Sodium Injection Solution Reconstituted 1 GM Inject 1 gram intramuscularly one time a day for UTI for 7 Days initiated on 5/17/2025. 2. On 5/21/2025 at 2:30 PM, V5 (IP Nurse) said R85 was receiving Vancomycin and Meropenem antibiotics. V5 said she was unsure why R85 was receiving Vancomycin via his gastrostomy tube but believed it was for prophylaxis use. V5 said she also believed R85 was receiving Meropenem for a UTI. Upon review, V5 said R85's McGeer's assessment form was only initiated for R85's Meropenem and did not include a review of his Vancomycin antibiotic use. V5 continued to review R85's form and said it was initiated for a review of a UTI with an indwelling catheter, but it was incomplete. V5 said she had to further clarify why R85 was prescribed his Meropenem because the form said it was for MRSA (methicillin-resistant Staphylococcus aureus) in his blood and urine, and R85's prescribed order said it was for MRSA and ESBL (Extended-Spectrum Beta Lactamases) in the blood. R85's McGeer Criteria for Infection assessment form reviewed on 5/21/2025 said R85 was started on Meropenem intravenously for MRSA in the blood and urine on 5/16/2025. The form did not include a review of R85's prescribed Vancomycin. R85's Order Summary Report dated 5/22/2025 showed active orders for Vancomycin HCI Oral Solution Reconstituted 50 MG/ML Give 2.5 ml via G-Tube one time a day for prophylaxis for 9 Days and Meropenem Intravenous Solution Reconstituted 500 MG Use 500 mg intravenously three times a day for MRSA, ESBL 145339 Page 19 of 20 145339 05/23/2025 Grove of Elmhurst, The 127 West Diversey Elmhurst, IL 60126

F 0881 in blood for 10 days. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Antibiotic Stewardship Program Policy dated 7/12/2024 said The facility will comply with federal regulations in establishing an antibiotic stewardship program .Document the dose, route, duration, indication .Establish best practices for use of microbiology testing .Perform Antibiotic Time Outs 3 days after the initial dose of antibiotic was started, a formal process of reassessment of the ongoing need for and choice of antibiotic is required to be performed by the clinical team as during this period, culture result is in . Residents Affected - Few 145339 Page 20 of 20