Inspection·May 7, 2023

F 0600 became agitated due to noises in the dining room and this is what likely caused him to react in such a way. Level of Harm - Minimal harm or potential for actual harm Nurse progress note dated 4/6/202316:18, written by V3 (LPN) reads: Residents Affected - Few Narrative: V4 (CNA) witnessed (R3) using his right closed fist to punch (R4) on her face. CNA immediately interfered and separated both residents. Writer heard the commotion and assisted CNA to separate both residents. (Facility Medical Director) here, seen resident with order to send resident to ER via 911.Local Authorities notified and arranged for 911 transport. ( Correction on the time above of People/Agencies notified. Incident happened at 15:00.MD notified at 15:10 DON notified at 15:01Administrator notified at 15:12. Interview with V3 (LPN) on 5/6/23 at 1:22PM, V3 stated that she was at the nurses station right across from the small dining room (during 4/6/23 incident) so she heard the commotion. V3 stated, I don't think there was any staff in there at the time, but I am right here (nurses station is approximately less than 15 feet from the dining room) and V4 (CNA) separated them quickly. R4 is very confused and disoriented. R3 is usually redirectable and calm throughout the day. On 5/6/23 at 4:02PM, V3 confirmed that V4 (CNA) reported the incident to her, just as she had charted and that R3 has a history of aggressive behaviors with loud environments. During interview with V4 (CNA) on 5/6/23 at 12:24PM, V4 stated that he was bringing a resident (on 4/6/23) into the dining room when he saw the incident. R4 likes to yell and R3 doesn't like loud noises. R4's lip was open a little at the bottom. At the time (of incident) we were in the middle of shift change and sometimes they might be alone momentarily. 5/6/23 at 1:36PM V2 (DON) was interviewed about the incident between R3 and R4 and stated that there should be staff in the dining room (with residents) and confirmed that R4 is confused and can get agitated which is not new for R4. V2 stated, staff try to keep R4 away from loud noises and if R4 is loud, they keep R4 away too and try to keep R4 in a calm environment. V2 added that she (V2) did not consider this incident abuse based on the residents' impaired cognition and intellectual disability and added that she did not think that R3 intended to harm R4. They both have Alzheimer's. 5/6/23 at 3:19PM, V1 (Administrator) was interviewed about the incident between R3 and R4 and stated that they (R3 and R4) were sitting in the dining room together and R3 hit R4. When R3 went to the hospital (after incident), they determined R3 had a UTI (urinary tract infection), and was treated with antibiotics. V1 stated. He's (R3) not normally aggressive. With his cognition, I don't believe that (R4) really knows because if you go back and ask him, he doesn't recall what happened. V1 confirmed that she did not substantiate abuse for this incident. Facility provided document titled, Abuse Prevention and Reporting- Illinois (last revised 10-24-22), which includes: .Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means (210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 If continuation sheet Page 2 of 4 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 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 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 caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CF R 483.5). An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines) . Resident-to-Resident Abuse (any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 If continuation sheet Page 3 of 4 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 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow its policy for using restraints and failed to prevent a physical restraint from being used for staff convenience for one resident (R1) in a sample of five residents reviewed for restraints. Residents Affected - Few Findings include: On 5-6-2023 at 3:10pm V8 (R1's Family member) said, on 4-23-2023 I came at 11:00am to see my family member (R1), she was in bed with a facility gown that was tied to the bed side rail and holding both legs next to each other, unable to move her legs freely. R1 was restrained. On 5-6-2023 at 11:00am V5 (Certified Nurse Assistant) said, on Sunday 4-23-2023 I was working here, I went to R1's room about 10:00 am and I provided morning care and since she likes to play with her feces, I folded the gown under her knees to avoid for her to reach her incontinence under garment. I should have never done that because it can be consider a restraint On 5-6-2023 at 1:25pm V2 (Director of Nursing) said, tied a gown under the knees is consider a restraint because R1's will not be able to move her legs freely. We consider that as a restraint. 3:30p V1 (Administrator) said, a gown tied at the knee level is consider a restraint, we are not supposed to restraint any residents. V1 presented: Restraints policy dated: 11-28-2012. Reads: The use of side rails as restraints is prohibited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 If continuation sheet Page 4 of 4