Inspection·September 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to monitor a resident during a change in mental condition. This resident was able to injure a resident by pushing a wheelchair aggressively, causing this resident to slide out of the wheelchair hurting her back. The failure affects one of three residents (R1) reviewed for resident-to-resident physical assault. Findings include: R1 is a [AGE] year-old female. R1's face sheet diagnoses are but not limited to high cholesterol, schizoaffective disorders, paranoid schizophrenia, and sciatica. R1's BIMS (Brief Interview for Mental Status), dated 07/18/2024, notes R1 is alert. R3 is a [AGE] year-old male. R3's face sheet diagnoses are but not limited to major depressive disorder, and bipolar disorder. R3's BIMS (Brief Interview for Mental Status), dated 06/06/2015, notes R3 is alert. On 09/14/2024, at 12:09 PM, V1 (Assistant Administrator) stated, (R3) is no longer in the facility. He went to a different nursing facility. He had never had any behavioral concerns. To my knowledge, he did not present with any changes in condition. I was in the building. I heard noises. I went into the hallway. I was told by my Social Services Department that (R3) was upset. I was told he had head butted staff. I was told that he may have gone into someone's room. 911 came. They took over from there. He was on a one to one. But the staff he head-butted was sent to the urgent care. No staff witnessed the incident between (R1) and (R3). On 09/14/2024, at 12:31 PM, R2 stated, (R3) pulled (R1) out of the wheelchair and put the wheelchair over her while she was down. (R3) had a tendency of yelling. (R1) was going to tell (R3) to keep it down. When (R1) went to tell (R3) to keep it down, (R3) yelled fu***** b****. Keep your mouth shut and stay out of my business. (R1) was sitting in the wheelchair, and she fell on the floor. She hit her back on the floor. I was scared because I thought I would be next. Staff was not too far, but it took them about five minutes to assess the situation. I was not hurt; it was just her. I heard him yelling before this occurred. It was like (R3) was not satisfied being in the facility, but he was very agitated. I do not feel safe here because there are other people that are here that must be watched and get agitated. On 09/14/2024, at 12:42 PM, R1 stated, (R3) was insulting to staff and tried to hit them. He was screaming. He was taking resident's lunches and throwing him. I went over to see what I could do. He got really enraged and he slammed my wheelchair into the bathroom door so hard that me and my (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 2 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 09/15/2024 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)