Health inspection·June 7, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement its abuse prevention policy by failure to complete abuse assessment and update abuse care plan after allegation of resident-to-resident physical altercation. This deficiency affects three (R25, R78 and R87) of three residents reviewed for Abuse prevention policy. Residents Affected - Few Findings include: 1. Review Incident report of Resident-to-resident physical altercation involving R25 and R87 completed by V1, Administrator, indicated on 3/22/24 at 7:05AM, upon entering room, V28, RN (Registered Nurse), observed R25 on the floor. Upon initial interview of residents, it appeared that there was a disagreement over the volume of R87's TV. As R25 attempted to scurry away back to his bed with R87's remote, he lost his balance and fell. V1 interviewed R25 on 3/25/24. R25 admits to trying to take R87's remote control on the morning of 3/22/24, as he felt the volume of his TV was too loud. R25 also admitted to then taking his cell phone off the bed after R87 grabbed the remote back. R25 alleged R87 pushed him when R87 attempted to get his cell phone back from him, causing him to lose his balance and fall. R25 was immediately assessed and was able to move all his extremities with only slight discomfort to his back. R25 was sent to local hospital for precautionary evaluation and returned soon thereafter with no new orders or injury. V1 interviewed R87 on 3/22/24 and 3/25/24. In both instances, R87 alleged on 3/22/24, his roommate R25 walked over to his bed unprovoked and grabbed the remote control off his bed. R87 was able to immediately retrieve his remote at which time R25 grabbed for his cell phone. As R87 attempted to grab his phone back, R25 lost his balance and fell as he tried to scurry away R87. R87 strongly denied ever pushing R25 at any time. There were no witnesses to the alleged incident. R25 was re-admitted on [DATE], with diagnoses listed in part but not limited to Psychotic disorder with delusion due to known physiological condition, bipolar disorder current episode depressed severe with psychotic features, Dementia with behavioral disturbance, Schizophreniform disorder, Alzheimer's disease, Cerebral infraction. Abuse/Neglect assessment done on 12/8/16 indicated he is at risk for abuse due to his history of abuse and substance abuse, as well as his mental health diagnosis and his history of abrasive/aggressive behavior. Abuse/neglect /trauma factors care plan for abuse neglect trauma assessment updated on 10/21/22. Both Abuse/neglect assessment and Abuse care plan intervention were not updated after the physical abuse resident to resident altercation on 3/22/24. R87 was admitted on [DATE], with diagnoses listed in part but not limited to Dementia with other behavioral disturbance, Paranoid personality disorder, Psychosis, Alzheimer's disease with late onset. Abuse/Neglect assessment done 2/10/22 indicated he at risk due to mental issues, presents with signs and symptoms of mood distress. Resident has history of exhibiting verbal outbursts when he becomes (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 145809 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 06/07/2024 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)