Inspection·July 29, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to repair leaking water from the air-conditioning unit in the resident's room. This deficiency affects 4 (R14, R20, R34 and R54) residents in the sample of 25 reviewed for Safe environment. Findings include: On 7/27/22 at 9:37AM, water was leaking from the air conditioning unit in R54's room, which caused a puddle of water on the floor going under the bed. Surveyor observed towel soaked with water placed at the base of the air conditioner. V10, Licensed Practical Nurse/LPN was showed problem in R54's room. V10 said she did not notice the puddle of water, and did not place the towel to absorb the water. V10 said no one reported to her there was leaking water from the air conditioner. V10 said, (R14) always carries a towel, she probably placed the towel to absorb the water. On 7/27/22 at 9:40 AM, R20, who resides in the same room, said V7, Maintenance Director, has been working with that air conditioner. R20 said V10, LPN, placed the towel there earlier. R34 ,who also resides in the same room, said she did not place that towel at the base of the air-conditioner. On 7/27/22 at 9:42 AM, V14, Certified Nursing Assistant/CNA said he is the assigned CNA for R54. V14 said he came in at 6:30 AM, and he already observed the towels were placed at the base of the air conditioner to absorb the leaking water. He did not report it to maintenance because it was too early. On 7/27/22 at 9:45 AM, V7, Maintenance Director, said the air conditioning unit has problems with the condenser. He said the drainage pipe was clogged, so the water instead of draining outside, it drains back to the inside, causing a puddle of water on the floor. He said it has had the same problem since last week. He said nobody told him of the water leaking problem again. He said staff should call him if there is problem so he could repair it immediately. On 7/27/22 at 10:01 AM, V6, Environmental Services, said they are short of housekeeping aides today. She said there is no assigned housekeeping aide in the unit until this afternoon at 3pm, but a housekeeping aide from other unit is available if needed. She said no one reported to her leaking water from the air conditioning unit in R54's room. On 7/27/22 at 3:02 PM , Requested facility's policy on Safe environment from V2, DON ( Director of Nursing) On 7/28/22 at 10:33 AM, Follow up requested policy from V2, DON. V2 said they don't have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 2 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 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 shave facial hair and provide nail care to a dependent resident. This deficiency affects one (R54) of 6 residents in the sample of 25 reviewed for Personal hygiene and Grooming. Residents Affected - Few Findings include: R54 was admitted on [DATE], with diagnoses to include Metabolic Encephalopathy, Multiple Sclerosis, Flaccid hemiplegia affecting dominant side, Cerebral Infarction due to occlusion or stenosis or the cerebral artery. R54's care plan indicates she has ADLs selfcare performance deficit related to hemiplegia of left sided extremities. R54 requires assistance with ADLs (Bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). On 7/26/22 at 11:30 AM, V11 CNA (Certified Nursing Assistant) said she just finished providing morning care and incontinent care to R54, and preparing her for mechanical lift transfer from bed to recliner chair. V11 said R54 needs total care with ADLs (Activity of daily living). Observed R54 with facial hair on chin area and long, dirty fingernails on both hands. On 7/26/22 at 12:17 PM, V11, CNA, said she performs personal hygiene and grooming to the resident on a daily basis during morning care. V11 said she is aware R54 has facial hair and dirty fingernails. V11 said she did not shave her, and did not do nail care. Reviewed R54's electronic medical record with V11, CNA and V12, CNA. There was no documentation in the plan of care where the CNAs documented care rendered, or R54 refused care. On 7/27/22 at 11:10 AM, V2, DON (Director of Nursing), said CNAs are expected to provide personal hygiene and grooming, including shaving facial hair and nail care to dependent resident during morning care. Facility's policy on General Care indicates: it is the facility's policy to provide care for every resident to meet their needs. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include but are not limited to ADL, wound care, medical needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 3 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to use hand splints to prevent/decrease further contractures for one of one residents (R4) reviewed for contractures in a sample of 25 residents. Findings include Care plan review, dated 7/15/22, includes, residents require use of right- and left-hand roll assistance program. The resident has an ADL Self Care Performance Deficit r/t disease process osteoarthritis .Hand roll to right and left hand to prevent further contraction until next review 10/12/22. On 7/26/22 at 11:30 AM, R4 was observed sitting up in a chair without splints to bilateral arms. R4 has contractures to both hands. On 7/26/22 at 11:50 AM, V13 (Electronic Medical Record/Medical Record Nurse) stated there is no order for hand splints. On 7/27/22 at 12:10 PM, V2 (Director of Nursing) and V9 (Restorative Nurse), both stated R4 should have a hand roll in her hands to prevent further contractures. Facility policy, dated 7/28/21, includes Policy Statement, It is the policy of this facility to assess for comprehensive nursing and restorative need upon admission . Procedures: 3. Nursing and Restorative Service may include the following .(c) Contracture Prevention and Management . (i). PROM/AROM Exercises, (ii). Splint/orthotic Management . 5. Evaluation as to the need of adaptive equipment/enabling device to help accommodate the resident's need, promote optimal functioning . 6Restorative Program shall be reflected and indicated in the resident's electronic restorative log and the frequency by the nurses, cnas and/or restorative aides . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 4 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a fall investigation to determine the cause of a fall, failed to update a resident's fall care plan after each fall incident, and failed to ensure a functional alarm was attached a resident who is at risk for falls. This deficiency affects 4 (R38, R72, R77 and R85) residents in the sample of 25 reviewed for Fall prevention management. Findings include: 1. R72 was admitted on [DATE], with diagnoses to include Disorder of the brain, Unsteadiness on feet, Gait and mobility abnormality. Lack of coordination, need for assistance with personal care, history of falling, and ataxic gait. R72's care plan indicates he is at high risk for falls. admission fall assessment, dated 4/1/19, re-admission fall assessment, dated 7/8/19, and re-admission fall assessment, dated 8/15/20, all indicated R72 is at high risk for fall. On 7/26/22 at 10:49 AM, V10, Licensed Practical Nurse/LPN said R72 had an unwitnessed fall in his bathroom on 7/11/22. R72's unwitnessed fall incident, dated 7/11/22 at 1:30 PM indicates: V10, LPN called by CNA (Certified Nursing Assistant) to R72's room and found him sitting on the bathroom floor next to the toilet. R72 stated, I tried to stand up after using the bathroom and I lost my balance and landed my butt on the floor. Head to toe assessment was done and staff transferred him back to his wheelchair by mechanical lift. No injuries observed at the time of the incident. On 7/27/22 at 9:47 AM, R72 said that he put on the call light, but only one came, so he went to the bathroom and transferred himself. On 7/27/22 at 10:05 AM, V10 LPN said she is the nurse who worked with him when he fell. She said she came to answer his call light, but he was already on the floor. On 7/27/22 at 10:10 AM, V5 MDS(Minimum Data Set)/Care Plan Coordinator said the Restorative Nurse is the one who does the root cause analysis and updates the fall care plan interventions. R72's fall incident report, dated 7/11/22, indicated no root cause analysis done and the fall care plan was not updated. On 7/27/22 at 10:22 AM, V9, Restorative Nurse, said after each resident fall, a fall investigation and root cause analysis of the fall is conducted. After investigation, the fall care plan should be updated based on root cause analysis, and the individualized care plan is updated to prevent future falls. V9 said a fall assessment is done upon admission, re-admission, quarterly, and after each fall incident. V9 said the fall assessment after each incident report is done by the floor nurse. Informed V9 that no fall assessment done after fall incident on 7/11/22. V9 said she did not do the root cause analysis and did not update the fall care plan interventions after the fall incident. She said it was not done. She added she works on the unit most of the time and overlooked it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 5 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/28/22 at 11:03 AM, V2, Director or Nursing/DON, said, Fall assessment is done upon admission, re-admission, quarterly, and after each fall incident. The fall care plan is updated based on root cause analysis after each incident to prevent future fall. 2. R38 was admitted on [DATE], with diagnoses not limited to: Diabetes, Hypertension, Dementia, symptomatic epilepsy. Fall risk assessment, dated 9/05/2020, indicated R38 is high risk for falls. R38 had a fall incident on 1/11/2021. Alarm list updated on 7/29/2022 indicates R38 has a bed alarm started on 5/13/2018. R38 is on the fall monitoring list, updated on 7/26/2022. R38 was not care planned as high risk for falls, and the care plan did not indicate use of a bed alarm. On 7/26/2022 at 10:50 AM, R38 was observed lying in bed with bed alarm. On 7/26/2022 at 11:55 AM, V16 (Nurse) checked the bed alarm, and said that it was off. V16 turned it back on, and said it should be turned on. On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check and inform V9 or Restorative department if it is not working. 3. R77 was admitted on [DATE], with diagnoses not limited to: Diabetes, unsteadiness of feet, lack of coordination, spinal stenosis, and polyosteoarthritis. admission fall risk assessment, dated 2/18/2020, indicated R77 is high risk for fall. R77 had a falls on 3/16/2021 and 4/16/2022. Care plan indicated high risk for falls, with intervention that includes bed sensor alarm to staff when R77 is trying to rise up without assistance to prevent fall. Alarm list updated 7/29/22 indicates R77 has a bed alarm started 4/06/2020. R77 is on the fall monitoring list updated on 7/26/2022. On 7/26/2022 at 10:45 AM, R77 was observed sitting in her wheelchair; no bed alarm was observed on her bed. On 7/26/2022 at 11:58 AM, V16 checked R77, and said R77 does not have any bed alarm. On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check, and inform V9 or Restorative department if it is not working. 4. R85 was admitted on [DATE], with diagnoses not limited to: Parkinson's disease, unsteadiness on feet, unspecified abnormalities of gait and mobility, unspecified lack of coordination, and history of falling. R85 fall risk assessment upon admission, dated 6/22/2021, indicates high risk for fall. R85 had a fall incidents on 7/6/2021, 7/24/2021, 8/10/2021, 8/19/2021, 9/8/2021 twice, 9/11/2021, 10/5/2021 and 3/16/2022. Care plan indicated high risk for falls, with intervention that includes provide use of bed alarm for safety and reminder to ask help or any assistance to prevent fall. Alarm list updated on 7/29/2022 indicated R85 had a bed and chair alarm started 7/6/2021. R85 is on the fall monitoring list updated on 7/26/2022. On 7/26/2022 at 11:18 AM, R85 was observed lying on her bed with bed alarm, but no wheelchair and chair alarm at bedside observed. On 7/26/22 at 11:18 AM, V16 checked the bed alarm, and said that it was off, and V16 turned the bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 6 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0689 alarm on. V16 said she was not sure where R85's wheelchair alarm was. Level of Harm - Minimal harm or potential for actual harm On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check, and inform V9 or Restorative department if it is not working. Care plan reviewed with V9 for R85 fall on 10/5/2021, and V9 admitted she updated the care plan on 7/28/2022. Incident report for R85 fall on 3/16/22 was reviewed with V9. V9 said the root cause analysis for 3/16/22 fall was not done. Residents Affected - Some Facility's policy on Fall occurrence indicates it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedures: 5. The fall coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. 7. Ultimately, the Fall coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. 8. The Falls Coordinator will add the intervention in the resident's care plan. 10. The interventions will be re-evaluated and revised as necessary. Facility's fall prevention program guidelines indicates: The fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs each residents by assessing the risk for fall and the implementation of evidence- based prevention interventions. Procedures: 5. All fall incidents shall be monitored, analyzed, root causes identified by the DON or designee. 8. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to: K. May utilize personal alarms when appropriate such as bed alarms, chair and motion sensor alarm and floor mat alarms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 7 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report pharmacist recommendations to the Physician. This deficiency affects one ( R113) of three residents in the sample of 25 reviewed for pharmacy medication review. Findings include: R113 is admitted on [DATE], with diagnosis to include Bipolar disorder and Major depressive disorder. Active Physician order sheet for 7/26/22 indicates she is on Divalproex Sodium ER oral tablet extended release 24-hour 500mg 3 tablets by mouth at bedtime for Bipolar depression. There were no laboratory orders written. Review of R113's consultant pharmacy recommendations to MD (Physician) form, dated 7/16/22, indicates R113 Divalproex Sodium ER 500mg tablets to take 3 tablets every night at bedtime recommending staff to obtain a serum drug level at this time to monitor the drug therapy. There was no physician response noted. Review of R113's medical records showed no documentation indicating R113's primary care physician was notified of the pharmacy's recommendation. R113's physician order sheet does not indicate an order of serum drug level of Divalproex to monitor therapy. On 7/28/22 at 10:43 AM, V2, Director of Nursing/DON said the pharmacist does monthly resident medication reviews. Any recommendation form received from the pharmacist will be called to the physician for approval as soon as possible. On 7/28/22 at 2:38 AM, V17, Consultant Pharmacist said the pharmacy medication review was done at the facility on 7/16/22. All pharmacy recommendations were sent to V2, DON, and V3, Assistant Director of Nursing/ADON on the same day for them to follow the recommendations made. Facility's policy on Monthly Drug Regimen Review indicates: it is the policy of this facility to ensure that medications are reviewed monthly by the pharmacist. Procedure: 2. The pharmacist must report any irregularities to the attending physician and the facility's Medical director, Director of Nursing and these reports must be acted upon. *Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug and the irregularity the pharmacist identified. *The attending physician must act upon the identified irregularity, if any, action has been taken to address it, it must be documented. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medial record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 8 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 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. Based on observation, interview, and record review, the facility failed to follow their Medication Storage Policy by not returning to the pharmacy expired medications belonging to R3, R4, R6, R19, and R112; the facility also failed to return, destroy or store seperately expired stock medications. This affects 5 residents (R3, R4, R6, R19, and R112) in the sample reviewed for medication storage. Findings: D - WING MEDICATION CART On 7/27/2022 at 10:23 AM, surveyor observed: 1. Latanoprost 0.005% ophthalmic solution, belonging to R4, opened on 4/23/22. Label indicates Refrigerate unopened. Store opened at room temperature. Discard after 6 weeks. 2. Glycopyrrolate/formoterol fumarate for R19 was not in a foil wrapper, and there was no indication of the date the medication was opened. Label indicates Discard 3 months after removal from the foil pouch. On 7/27/22 at 10:41 AM, V13, Licensed Practical Nurse (LPN), verified there is no open date for R19's Glycopyrolate/formoterol fumarate, and R4's Latanoprost ophthalmic solution was opened on 4/23/22. V13 said no open date is needed for the inhaler, but the Latanoprost should have been discarded. A - WING MEDICATION CART On 7/27/2022, at 11:35 AM, the following medications were observed in the cart: 1. Docusate sodium 100mg tablet with 75 tablets remaining in the bottle, with expiration date of 6/2022. 2. Vitamin D3 10mcg (400 IU) with 55 soft gel capsules left in the bottle, and an expiration date of 10/2021. 3. Prochlorperazine 10 mg for R6 with 2 pills left, with expiration date of 5/4/2022. 4. Prochlorperazine 10 mg for R112, with use by date of 5/30/22, and with 30 pills left. 5. Phenazopyridine 200 mg, with use by date 5/30/2022, with 7 pills left. 6. Amlodipine 5 mg for R3, with use by date of 2/28/22. 7. Microdot glucose gel, with use by date of 6/2022, with 2 tubes left. On 7/27/2022, V10, LPN, verified Docusate, Vitamin D3, R6's Prochlorperazine, R112's Prochlorperazine and Phenazopyridine, R3's Amlodipine and Microdot glucose gel were all expired. V10 added R112's Prochlorperazine was discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 9 of 10 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 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Northbrook,the 263 Skokie Boulevard 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 0761 Level of Harm - Minimal harm or potential for actual harm On 7/28/2022 at 2:00 PM, V10 said they removed expired medications, and put them in a bag to return to the pharmacy. On 7/28/2022 at 2:30 PM, V2 Director of Nursing (DON), said she expects her staff to remove expired medication, put them in the return to pharmacy bag, and hand it over to her (V2) or V2's assistant. Residents Affected - Some On 7/28/2022 at 2:45 PM, V2 said the facility does not have a policy on Expired Medication, and they don't need to date Glycopyrrolate/formoterol fumarate when opened. On 7/28/2022 at 3:00 PM, V2 confirmed with the facility pharmacist Glycopyrrolate/formoterol fumarate should be dated once opened. V2 further said the pharmacy told her (V2) the medication is no longer effective after being opened for 3 months. Policy Title: Discontinued Medications: Policy When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are stored in a secure and separate area from the active medications. Residents whose medications are sent home on discharge are provided medications in accordance with state laws and regulations, and according to discharge medication policies. Procedures 2. Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 10 of 10