Health inspection·December 14, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not aware of R4 and R5 having history of altercations/incidents. V12 said she monitors all her residents and ensure R4 and R5 are separated. On 11-30-23 at 11:49 AM, V18 (Social Services Director/SSD) said R4 is alert, oriented x2-3, and able to make her needs known. R4 has bipolar disorder, dementia with behavior disturbance, dementia with agitation, major depression, low self-esteem, and generalized anxiety disorder. R4 has delusions, hallucinations, and hospitalized due to psychosis. R4 has frequent delusions and seeks reassurance from staff. V18 said she is not aware of any previous altercations between R4 and R5. V18 said she is not aware of R4 having aggression towards any other residents. R5 is alert, oriented x2-3, and able to make her needs known. V18 is not aware of R5 having aggressive behaviors. R5's Progress Note, dated 6-7-23, documents: Resident reported to this writer that she was hit on right upper arm by a peer this morning. ADON (Assistant Director of Nursing), social services, and administrator were notified. This writer performed head to toe assessment. No new skin concerns noted. Resident verbalized pain on right shoulder and radiating to right elbow. Resident has chronic pain on right shoulder and verbalized she received lidocaine cream this morning to area as ordered. This writer offered pain reliever medication and resident refused at first. This writer observed resident able to actively move right elbow and right shoulder with no restrictions but resident continues to verbalize pain. Cold pack was applied to right shoulder. No behavior observed at this time. At 10:45 AM, this writer offered Tylenol for pain management and resident agreeable. Tylenol 650 mg was administered by mouth and effective. This writer notified NP (Nurse Practitioner) with new order for STAT x-ray of right upper extremity (right shoulder, right humerus, right elbow, right forearm). This writer notified (company) of STAT order. Resident was seen by occupational therapy this shift. Vitals: 140/86BP 96.9T 72P 18R 96% oxygen saturation at room air. Will continue to monitor for any changes in condition. R5's Progress Note, dated 6-7-23, documents: Resident was involved in an incident this morning with another peer. Facility protocol was initiated. Resident agreeable to meet with psychotherapist today. Voicemail left for guardian. Awaiting call back. R5's Radiology Note, dated 6-8-23, documents: 1. Right forearm AP and lateral- Relatively good bone mineral density. No fracture, dislocation, bone destruction or periostitis. Small olecranon spur at the triceps tendon insertion. Otherwise, normal right forearm x-ray. No comparison exam. 2. Right Humerus, AP and Lateral - Good bone mineral density. No fracture, dislocation, or other bony abnormality. Normal right humerus x-ray 3. Sternum, oblique and lateral - Good bone mineral density. No fracture or retrosternal soft tissue swelling. No other skeletal abnormality. Normal sternum x-ray. No comparison exam. 4. Right elbow, three views -Good bone mineral density. No fracture, dislocation, or evidence of joint effusion. No degenerative arthrosis. Small olecranon spur at the triceps tendon insertion. Small Otherwise, normal right elbow x-ray. No comparison exam. 5. Right shoulder, three views Good bone mineral density. No fracture, dislocation, or significant degenerative change. No other skeletal abnormality. Normal right shoulder x-ray. No comparison exam. Relayed Results: Faxed results to De. [NAME] Follow up: Will endorse to morning nurse in AM. Initial State Reportable, dated 6-7-23, documents: Allegation Details: What was the reported allegation of abuse? On 6-7-23 at approximately 8:40 AM, resident (R5) stated that fellow resident (R4) hit her on the shoulder as they passed each other in the hallway earlier in the morning. (R5) was assessed and noted with no redness or bruising. (R4) admitted to hitting (R5) claiming they were arguing over something, As a result, (R4) will be sent to hospital for an evaluation. Residents MD and guardian were made aware of the incident. (R4) is her own responsible party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Final State Reportable, dated 6-7-23, documents: Narrative of the Final Report Investigation: On 6-7-23 at approximately 8:40 AM, resident (R5) stated that fellow resident (R4) hit her on the shoulder as they passed each other in the hallway earlier in the morning. Both residents were immediately separate and monitored for safety. Upon initial assessment, (R5) was noted with no redness, bruising, or discomfort. Later in the day on 6-7-23, R5 complained of slight discomfort to her right shoulder. Tylenol was given with good result. Precautionary x-ray was taken with negative results, (R5) did not complain of any additional lingering discomfort. (R4) admitted to hitting (R5) claiming they were arguing over something silly but couldn't exactly recall what it was. (R4) does not have a history of physical aggression towards staff or peers and regrets the way she acted. Due to her behavior, (R4) was admitted to local hospital. As both ladies are often seen hanging around each other, both were strongly encouraged to stay away from one another upon (R4's)return from the hospital. Residents MD (Medical Doctor) and guardian were made aware of the incident. (R4) is her own responsible party. Petition for Involuntary/Judicial Admission, dated 6-7-23, documents: (R4) is a 62 y/o Caucasian female with dx (diagnosis) of Bipolar D/O (disorder), Major Depressive D/O. Generalized Anxiety D/O, & suicidal ideations. Resident is presenting with verbal and physical aggression towards peer. Resident placed on 1:1. Resident is need of immediate hospitalization and evaluation to prevent harm to self and/or others. On 12-1-23 at 11:39 AM, R4 said she was not romantically involved with R10. R4 said R10 gave her an unwanted kiss on the cheek. R4 said she did not ask or was prepared for a kiss. R4 said she did not attempt to stop R10 because she was afraid him. R4 said she heard rumors of R10 coming out of prison, and R4 was scared of and intimidated by R10. R4 said R10 kissed R4, went away, and R4 reported R10 to Social Services. R4 said R10 was sent to hospital for delusional behaviors. R4 said she is satisfied with facility handling the incident. R4 said she has seen R10 talk to other residents about religion prior to this incident. On 12-1-23 at 11:18 AM, R10 said he kissed R4 on the forehead. R10 said R4 was not expecting this kiss from R10. R10 said R4 was not protesting or telling R10 to stop. After the kiss, R10 went away. Later the staff questioned R10 about why he kissed R4. R10 said he was told that he was going to the hospital because he kissed a girl on the forehead without permission. On 12-1-23 at 12:11 PM, V18 (Social Services Director/SSD) said R10 is alert, oriented, and able to make his needs known. R10 has a lot of delusional behaviors and hallucinations centering around religion. V18 said R10 had delusions prior to SSD employment at facility. R10 is seen by psychiatrist and psychotherapist. V18 said R10 would receive standard rounding by staff. Religious delusions were not a threat to himself or others, however an unwanted kiss was a behavior escalation and R10 was petitioned for psychiatric evaluation. On 12-1-23 at 10:46 AM, V23 (Licensed Practical Nurse/ LPN) said R4 is alert, oriented, and able to make her needs known. R4 is attention seeking. V23 said she was made aware of a R10 did something to R4. V23 said this was not witnessed by V23, but it was reported R10 kissed or touched R4 on the forehead. V23 said R10 was talking about religion and having delusional moments. V23 found R10 on the floor and asked what he was doing and R10 said why are you disturbing me? V10 said he was praying to Jesus and Jesus was sitting next to him. V23 said she notified psychiatrist who gave order to petition due to delusional behaviors. V23 thinks R10 was admitted at that time. V23 said R4 said R10 did something she did not like and R4 didn't give any detail. V23 called social services who met with R4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R10's Social Service Progress notes, dated 7-10-23, 7-11-23, 7-17-23, and 7-19-23, documents R10 having delusional episodes. Initial State Reportable, dated 7-19-23, documents: On 7-19-23 at approximately 9:15 AM, (R4) alleged to social worker that earlier in the morning resident (R10) pecked her on the forehead as he said Good Morning to her. She claimed to never have any prior issues with (R10). Both residents were immediately separated and placed on 1:1 observation. (R10) will be sent for psychiatric evaluation due to an increase in delusional thought process. Residents MD made aware of the allegation. Both residents are their own responsible parties. Final Reportable, dated 7-24-23, documents: Narrative of the Final Report Investigation: On 7-19-23 at approximately 9:15 AM, (R4) alleged to social worker that earlier in the morning resident (R10) pecked her on the forehead as he said Good Morning to her. She claimed to never have any prior issues with (R10), nor has (R10) ever displayed such behavior in the past. Writer spoke to (R10) soon thereafter. (R10) admitted to lightly pecking (R4) on her forehead while saying 'good morning' to her that day. (R10) claimed to be good friends with (R4), and did not mean to make her feel uncomfortable in any way. (R10) admitted to this write that he regretted what he did and apologized to (R4). Both residents were immediately separated and placed on 1:1 observation. (R10) was educated /counseled on displaying appropriate behavior towards peers. (R10) was sent to local hospital for psychiatric evaluation due to an increase in delusional thought process. Upon return, both residents were encouraged to stay away from one another. Residents MD made aware of the allegation. Both residents are their own responsible parties. Care Plans updated. Petition For Involuntary/Judicial admission documents: (R10) is a 60 y/o Caucasian male with dx of Schizoaffective D/O, Bipolar D/O, Major Depressive D/O, & Anxiety D/O. Resident is presenting with an increase in delusional though content and hallucinations centering around religion. Resident is intrusive towards staff and peers, pushing his religious beliefs onto others. Resident is in need of immediate hospitalization and evaluation to prevent harm to self and/or others. Abuse and Neglect Policy, dated 7-14-23, documents: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 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 interview and record review, the facility failed to follow hospital discharge instructions and neurosurgeon's recommendation for a repeat CT (Computed Tomography) scan of head prior to restarting anticoagulant therapy. This affected one of three residents (R1) reviewed for physician orders and discharge instructions. Residents Affected - Few Findings Include: R1 was admitted in the facility on 10/12/23. R1 had right temporal parietal intraparenchymal hemorrhage and was taken emergently for right craniotomy for hematoma evacuation on 10/3/23. Hospital record on 10/17/23 hospitalization reads: Per Neurosurgery recommendation, R1 needs repeat CT in approximately one week with follow up prior to determining whether to restart formal AC (Anticoagulant). Physician order sheet Warfarin 2.5 mg by mouth in the evening for 3 days, start date 11/3/23, with order date on 11/2/23, and Enoxaparin 60mg/0.6ML two times a day, start date 11/8/23, with order date of 11/7/23. On 11/21/23 at 1:30PM, V4 (Registered Nurse/RN) stated V4 received a call from neurosurgery nurse and instructed to have the INR in therapeutic level before the CT scan can be done. V4 stated V4 relayed this call to V5 (Nurse Practitioner/NP), and V5 ordered to start R1 on warfarin 2.5mg. On 11/21/23 at 2:20PM, V5 (Nurse Practitioner) stated, (R1) has an aortic valve replacement, goal is to have INR of 2.5 to 3.5 and we have to play with the dose because INR was low. November 7, INR was 1.1 and (V14, Physician) ordered to give warfarin and start in enoxaparin injection until INR is in therapeutic level. On 11/28/23 at 1:45PM, V14 (Physician) stated V14 was the covering physician, and the INR result was relayed to V1,4 and the result was not in therapeutic level, and V14 added enoxaparin injection order. When asked if V14 was aware during hospitalization R1 was placed in warfarin with Enoxaparin Bridge and on 10/3/23 developed large right temporal parietal intraparanchymal hemorrhage, V14 stated V14 was not aware about the bleeding, and he based his order on the stroke diagnosis and heart valve replacement. V14 stated INR was in the low level, and would like it in the therapeutic level fast. On 11/29/23 at 11:00 AM, V5 (Nurse Practitioner) stated V5 was aware about the brain bleed upon initial admission in the facility, and V5 documented it in history and physical on 10/13/23. When V4 (RN) called and relayed neurosurgery wants R1 to be in the therapeutic level of INR, V5 started warfarin and not enoxaparin. V5 was on vacation when enoxaparin was started, and V5 knew the enoxaparin was added. V5 spoke to R1's attending physician, and agreed to keep the enoxaparin injection order along with warfarin, because INR was not in therapeutic level. V5 denied communicating with neurosurgeon about anticoagulant medication prior and while on warfarin and enoxaparin, while R1's was in the facility. On 11/20/23, R1 sent out to hospital due to abdominal bleeding at the injection site. Was found to be having acute subdural hemorrhage, without much compression of the brain and or midline shift. Hospital Record, dated 11/20/23, reads: 10/17/23, R1 was evaluated for chest pain with new T wave (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete inversion and elevated troponin. In lights of R1's recent neurosurgical intervention and held anticoagulation, we were contacted for further support in R1's management. Repeat CT head was reviewed with our team with improving heme, no acute hemorrhage. If anticoagulation was indicated from a cardiac standpoint, it was advised that heparin could be started preferably without boluses. Recommended repeat CT head when patient reached therapeutic levels and close neurologic monitoring. Bridging was not recommended given bleed risk per discussion with cardiology. Event ID: Facility ID: 145809 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 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 interviews and record reviews, the facility failed to use the proper equipment when providing incontinence care. This affected one of three residents (R11) reviewed for safety during care. This failure resulted in the use of a sit to stand device while providing incontinence care, contributing to R1 falling and sustaining a right shoulder fracture. Findings include: R11's MDS (Minimum Data Set), dated 7/7/23, notes R11's BIMS (Brief Interview for Mental Status) score is 15 out of 15. R11 is totally dependent on two persons physical assistance with transfers. R11 requires extensive assistance of two persons physical assistance with toileting. Functional limitation in range of motion notes impairment in both upper and lower extremities. R11's restorative assessment, dated 7/3/23, notes R11 with limitation in range of motion (flexion and extension) of both shoulders and both knees. R11's ADL (activities of daily living) care plan, initiated 4/26/2017, notes R11 has an ADL self-care performance deficit related to impaired balance. R11 has history of falls, limited balance and gait is unsteady, and limited mobility. On 4/22/2021, use mechanical lift (sit to stand) for transfers was added. The focus of this care plan was updated on 2/19/2022 to include discontinue sit to stand lift device now and use full mechanical lift device due to bilateral shoulder pain. R11's incontinence care plan, initiated 4/26/2017, notes R11 displays total bowel/bladder incontinence related to impaired mobility. R11 is unable to stand without staff interventions. R11 with obesity, weakness, and easily gets tired. The focus of this care plan was updated on 8/1/23 to discontinue use of mechanical lift (sit to stand) due to shoulder injury, limited range of motion especially of right shoulder. R11's falls care plan, initiated 4/26/2017, notes R11 is at high risk for falls related to incontinence, muscle weakness, lack of coordination, and unable to stand without staff interventions. On 12/1/23 at 1:10 PM, R11 who was assessed to be alert and oriented x 3, stated she is not able to bear weight on her legs. R11 stated V36, CNA (Certified Nursing Assistant) was using sit to stand lift device, and R11 fell hitting right upper arm and shoulder on floor. On 12/1/23 at 11:55 AM, V27 (Rehabilitation Director) stated R11 was seen by skilled therapy from February to March 2023. V27 stated at the time R11 was discharged from skilled therapy, it was recommended R11 use full mechanical lift device. On 12/1/23 at 1:20 PM, V8 (Restorative Nurse) stated R11 likes staff to use sit to stand lift device when providing incontinence care. V8 stated R11 was assessed and is appropriate for full mechanical lift device, not the sit to stand lift device. V8 stated residents have to be able to bear weight in order to use the sit to stand lift device. V8 stated R11 let go of the bar on the lift device with R11's right hand, and the CNAs lowered R11 to the floor. V8 stated V8 has educated R11 and staff regarding transferring R11 with full mechanical lift device for safety reasons. V8 stated the fall was due to a judgment error of staff to use sit to stand rather than full mechanical lift device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 - Actual harm Residents Affected - Few On 12/5/23, V36, CNA (Certified Nursing Assistant) stated V36 was providing incontinence care using the sit to stand lift device, R11 started to slide, and V36 and another CNA lowered R11 onto the floor. V36 stated when R11 is sitting in the wheelchair, the sit to stand lift device is used for incontinence care. R11's physical therapy discharge note, dated 3/21/23, notes R11's functional assessment for transfers with sit to stand - not applicable, chair/bed to chair transfer - dependent, toilet transfer - dependent. R11's mobility function score is 3 out of 12. R11's occupational therapy discharge note, dated 3/27/23, notes R11's functional assessment for toileting hygiene - dependent. R11's mobility function score is 0 out of 12. R11's hospital record, dated 7/27/23, notes, (R11) presented to the emergency room with complaints of right shoulder and elbow pain. (R11) has history of chronic right shoulder pain. (R11) reported last night she was being assisted in transfer with CNA using lift device and (R11) was standing with lift, then fell landing on her right shoulder. (R11) complained of increased right shoulder pain. X-rays done at facility reports possible humeral neck fracture. (R11) with bilateral lower leg lymphedema. Right shoulder x-ray shows comminuted fracture of the proximal humerus. Right elbow x-ray shows questionable impaction fracture of the right radial neck. The manufacturer's instructions for use of sit to stand lift device includes, but is not limited to, individuals must be able to support the majority of their own weight, otherwise injury can occur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145809 If continuation sheet Page 8 of 8