Health inspection·May 18, 2023

F 0686 available. Level of Harm - Actual harm R49's Skin Evaluation dated 03/15/2023 documents unstageable pressure wound to right heel with measurement of 3.0 x 2.5 x 0.3. Risk factors listed not limited to depression and psychotropic drug use. Residents Affected - Few R49's care plan with last completion date of 3/14/2023 indicates that resident has an actual impairment to skin integrity related to right heel unstageable wound, date initiated 07/11/2022. Interventions indicated low risk with weekly skin checks and report abnormalities to the nurse (initiated 07/11/2022); off load heels as ordered (initiated 07/11/2022); turn and reposition at least every 2 hours and as needed (initiated 07/11/2022). No intervention for heel protectors noted. R49's Minimum Data Set, Section M dated 03/08/2023 indicates R49 has one or more unhealed pressure ulcers/injuries and is not on a turning/repositioning program. No documentation noted of heel protector use. R49's Skin Alteration Nursing Evaluation dated 9/21/2022 showed a new unstageable pressure wound to right heel that measured 6 centimeters (cm) x 5 centimeters (cm); no depth was documented. Per skin assessment evaluation, an unstageable wound indicates full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Last Skin Evaluation (Quarterly + Comprehensive) dated 07/11/2022 showed no current Braden pressure ulcer assessment score result. R49's Wound Specialist assessment dated [DATE] showed risk factors that contributed to and/or increased risk of resident's unstageable right heel wound as urinary incontinence, use of stool softener, and in need of assistance with activities of daily living (ADL's). Pressure relieving devices listed were: specialized air mattress (low air loss), heel protectors, and offload with green wedge. R49 has active physician orders to cleanse right heel with normal saline, pat dry, apply skin prep to peri wound, apply [calcium alginate] dressing to wound bed, and secure with dry dressing every day shift, every other day for wound care and as needed for soilage/dislodgement last revised 05/17/2023 and pressure relieving mattress. No order noted for heel protectors or offload with green wedge. Reviewed facility Skin Care Treatment Regimen policy last revised 07/28/2022 that reads in part: Policy Statement: it is policy to ensure prompt identification and documentation for residents with skin breakdown Procedures: 5. refer skin breakdown to the skin care coordinator. 6. residents unable to turn and reposition themselves will be turned and repositioned every 2 hours. 9. residents with stage III and/or IV pressure ulcer will be placed in specialized air mattresses like low air loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 2 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform comprehensive pain assessments as scheduled to promote effective pain management; failed to administer pain medication as requested/needed by a resident to prevent the negative effect of uncontrolled pain on a resident's function and mood; and failed to follow their pain policy and procedure for 2 of 4 (R115, R129) residents reviewed for pain management in a sample size of 30. Residents Affected - Few As a result, R115 was left in periods of unbareable pain level which causes him to cry out to staff for medication for pain relief. Findings include: 1. R115's face sheet showed he is a [AGE] year-old male with a past medical history not limited to: generalized osteoarthritis, anxiety, idiopathic chronic gout, calculus of the kidney and fatigue. He admitted to the facility on [DATE]. R115 with active physician orders for: Pain Assessment: Numeric Scale (0= No Pain; 1 to 3= Mild Pain; 4 to 7= Moderate Pain; 8 to 10= Severe Pain) every shift; tramadol oral tablet 50 milligrams (mg) give 1 tablet by mouth every 6 hours as needed for severe pain 4-10; gabapentin oral tablet 800mg, give 1 tablet by mouth three times a day for neuropathic pain; acetaminophen oral tablet 325mg give 2 tablet by mouth every 6 hours as needed for mild pain 1-3. R115's incomplete admission Pain assessment dated [DATE] 12:03 showed he had pain or was hurting at any time in the last 5 days, and he frequently had moderate pain levels rated at 6/10 on numerical pain scale during those 5 days. Pain frequency, Pain effect on function, Pain intensities and indicators not completed. R115's care plan with last completion date of 04/24/2023 reads: I present with risk factors r/t acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history and present mental health symptoms (initiated 01/11/2023). Goal: I will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect (initiated 01/11/2023, target Date 04/14/2023); At risk for pain related to multiple diagnoses (initiated 01/09/2023). Interventions: Resident would like to be educated on overall pain management, especially on different pain-relieving methods and would like to receive pain relief upon request (initiated 01/09/2023). On 05/15/23 at 1:27 PM, R115 said V22 (Registered Nurse) is unpleasant to him, there's no consistency with his gabapentin and pain medication administration when she (V22) works because she doesn't administer his pain medications as requested which causes him to wait and cry in pain for her to bring my pain medicine. He said this has been ongoing since admission. R115 then said he has pain every day, most of the day and has asked for something stronger than acetaminophen, but he doesn't always receive it. R115 added that his pain level is usually 7-8 and doesn't always receive his medications when he needs them. R115 also said last week, V22 was his nurse and he had to wait 2-3 hours for pain medicine. R115 then said he feels sad and frustrated and can't even think right when he's in so much pain. R115 added that he fears retaliation for reporting his issues regarding his pain medications. Resident was observed to be visibly distraught and saddened during interview. On 05/15/23 at 01:32 PM, V12 (Licensed Practical Nurse) said R115 and his daughter both talked to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 3 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 0697 her on Saturday regarding R115 having problems with a nurse (later identified as V22) about pain medication administration times. Level of Harm - Actual harm Residents Affected - Few On 05/16/2023 at 12:06 PM, R115 rated his pain level on a numerical scale between 00-10 at 6-7. On 05/17/2023 at 01:00 PM, R115 rated his pain level on a numerical scale between 00-10 at 6. On 05/17/2023 at 3:40 PM, V16 (Regional Nurse Consultant) said R115 should have had a pain assessment done last month. V16 then said pain assessments should be done every shift for every resident, and if a resident is on pain medications, they should assess their pain level before and after administering pain medication then follow-up within an hour. V16 added that comprehensive pain assessments should be completed quarterly; said one will be completed for R115. On 05/17/2023 at 3:42 PM, V22 (Registered Nurse) said last Wednesday on the evening shift, R115 came out of his room and asked for his meds. She had told him he needed to wait because she was on the phone with the doctors' office. After the call, V22 said R115 was at her cart and said to her you always make me wait and rated his pain at 6-7; R115 always rates his pain at 6-7. V22 then said he sometimes asks for Tramadol because the acetaminophen doesn't work for him. V22 added that V2 (Director of Nursing) informed her on Monday that she will no longer care for R115 per resident request because of the Wednesday incident regarding delayed pain medication administration. On 05/17/2023 at 3:40 PM, V16 (Regional Nurse Consultant) provided last comprehensive/quarterly pain assessment that showed he had pain or was hurting at any time in the last 5 days, and he had severe pain levels rated at 7/10 on numerical pain scale during those 5 days. Assessment also showed R115's pain effected his mood, music and as needed (PRN) medication alleviate his pain. On 05/17/2023 at 3:59 PM, V21 (Physician) said R115 is alert and can make his needs known so, if he is voicing high levels of pain from 6-7, then he is not comfortable, and his pain is not being managed. She then added that it has not been reported to her of R115's uncontrolled pain. Reviewed R115's medication administration record (MAR) for March 2023 that showed he only received acetaminophen (used for mild pain rated 1-3) on the 29th and was not administered tramadol (used for severe pain 4-10) for the entire month. April 2023 MAR showed he was administered acetaminophen on the 10th, 11th and 19th, and was only administered tramadol on the 25th. May 2023 MAR showed he was administered acetaminophen on the 6th and 7th and had an increased amount of tramadol administrations on the 7th and 8th, and 10th through the 17th with minimal effectiveness noted. Reviewed Pain level Summary from 05/01/2023-05/17/2023 that indicated R115 rated his pain level at 5 or higher a total of 18 times. Reviewed Pain policy and procedure last revised 07/28/2022 that reads: Policy Statement: It is the policy of the facility to ensure all residents are assessed for pain in every situation where there is a potential for pain. Procedures: - After the administration of prn pain medication, the resident will be assessed for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 4 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 0697 effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer the lack of relief. Level of Harm - Actual harm Residents Affected - Few 2. R129 is a 55-year -old female admitted to the facility on [DATE] with diagnosis including but not limited to Anoxic Brain Damage, Neuromuscular Dysfunction of a Bladder, Gastrostomy Status, Colostomy Status, Aphasia, and Necrotizing Fasciitis. R129's Physician Order Sheet dated 03/01/2023 reads in part, Oxycodone HCL Oral Solution 5mg/5ml *Controlled Drug* Give 2.5ml by mouth every 6 hours as needed for moderate to severe pain. Per record review, R129's pain assessment reads pain level at 0 on each of three shifts in March, April, and May 2023 except for: 03/02/2023, 03/06/2023, 03/07/2023, 03/12/2023, 03/13/2023, 03/20/2023, 03/27/2023, 04/07/2023, 04/17/2023 R129's pain level assessed between 1-5. Per record review, R129's Controlled Drug Administration Record reads that R129 received schedule II controlled pain medication at least once a day in March, April, and May 2023 except for: 03/05/2023, 03/19/2023, 03/30/2023, 03/31/2023, 04/02/2023, 04/03/2023, 04/05/2023, 04/09/2023, 04/10/2023, 04/11/2023, 4/16/2023, 04/21/2023, 04/23/2023, 04/27/2023, 04/28/2023, and 04/29/2023. Per record review, R129's Medication Administration Record reads that R129 received schedule II controlled pain medication at least once a day in March, April, and May 2023 except for: 03/03/2023, 03/05/2023, 03/19/2023, 03/30/2023, 03/31/2023, 04/02/2023, 04/03/2023, 04/05/2023, 04/09/2023, 04/10/2023, 04/11/2023, 04/16/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/24/2023, 04/27/2023, 04/28/2023, 04/29/2023, and 05/01-06/2023. Per record review, neither R129's pain assessment, Controlled Drug Administration Record, nor Medication Administration Record for schedule II controlled pain medication align; multiple discrepancies noticed. R129's schedule II controlled pain medication should be given only on days with pain assessed at greater than 0. On 5/17/2023 at 1:18 PM Surveyor interviewed V17 (Registered Nurse/ Clinical Care Coordinator), V17 (RN/CCC) stated, R129 had some sort of traumatic experience at a dentist office. She suffered anoxic brain injury from that. She is on schedule II controlled pain medication. We know that R129 is in pain when she has facial grimacing, body guarding, or screaming. R129's family also said that her pain threshold is high. R129 is able to say when she is in pain, but because of her brain injury, there is some disconnect in communication. Residents are assessed for pain on every shift, and it is documented in resident's electronic health record. R129 would generally score 6-7 on pain scale. On 05/17/2023 at 02:14 PM Surveyor interviewed R129. R129 indicated that she is in some pain at the moment and that she is usually in pain. R129 does not recall any of the nurses asking about pain on the scale from one to 10. On 5/17/2023 at 3:48 PM Surveyor interviewed V21 (Attending Physician), V21 stated, R129 can articulate her needs and is appropriate to answer to scale pain. Facility Pain policy dated 07/28/2022 reads in part, It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 5 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to follow controlled medications count policy by failing to maintain an accurate count of schedule II controlled pain medication for 1 of 85 (R129) residents during the medication storage and labeling task. This failure has a potential to affect all 133 residents residing at the facility. Findings include: On 5/15/23 at 9:45 AM, V1 (Administrator) presented survey team with facility matrix showing 133 current residents. On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. R129's oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) bottle - surveyor observed about half an inch of medication at the bottom of the bottle. Per R129's controlled drug administration record for schedule II controlled medication, last signed out amount on 05/07/2023 by V18 (Licensed Practical Nurse) was 165.5 milliliters. Surveyor requested V18 (LPN) to measure remaining schedule II controlled medication in the bottle; measured amount of remaining medication in the bottle was 16 milliliters; 149.5 milliliters discrepancy noticed. R129's Physician Order Sheet dated 03/01/2023 reads in part, Oxycodone HCL Oral Solution 5mg/5ml *Controlled Drug* Give 2.5ml by mouth every 6 hours as needed for moderate to severe pain. On 5/17/2023 at 9:54 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, We're still doing the investigation. I talked to several nurses. Sometimes nurses miss to sign medical administration record and controlled drug administration sheet. I work every weekend and at least every other weekend I do spot checks in medication carts. There was no discrepancy noticed. Appropriate in-services are already started. Moving forward, Assistant Director of Nursing, MDS nurses, EMAR nurse, restorative nurse, and psychotropic nurse, will do narcotic count at least on the daily basis to check for any discrepancies. We never had issues like this before. V18 (Licensed Practical Nurse) mistook R129's medication for another liquid medication. V2 (DON) further indicated that V18's (LPN) mistake created the discrepancy in R129's schedule II controlled medication. On 5/17/2023 at 10:23 AM Surveyor interviewed V17 (Registered Nurse/ Clinical Care Coordinator), V17 (RN/CCC) stated, R129's schedule II controlled medication was at the appropriate line on the bottle when I signed it out on both 04/17/2023 and 04/30/2023. There was no discrepancy at the time. Surveyor asked V17 (RN/CCC) to clarify controlled medication administration process, V17 (RN/CCC) stated, If controlled medication is scheduled, it's scheduled, when it is to be given as needed, we assess pain and then we administer it. I look at the order, dose, last time was given, and I administer controlled medication to the appropriate resident, I then, sign it out on controlled drug administration sheet and in the Medication Administration Record. Surveyor asked how does V17 (RN/CCC) know the process of controlled medication administration, V17 (RN/CCC) said that nurses receive training upon hire and as needed during in-services. She does not remember when the last controlled medication administration in-service was, but she was hired in November of 2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 6 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/17/2023 at 11:01 AM Surveyor interviewed V18 (Licensed Practical Nurse), V18 (LPN) said that on the morning of 05/07/2023 R129 was yelling, and V18 (LPN) had to give her schedule II controlled pain medication. After V18 (LPN) gave R129 2.5 milliliters of medication, she recorded 23.5 milliliters on the first page of controlled drug administration sheet based on the mark on the bottle. Around 3:00 PM V18 (LPN) gave another dose of 2.5 milliliters to R129, and at that point, she discovered the second page of controlled drug administration sheet for R129's schedule II controlled medication. V18 (LPN) thought it was the second bottle and that's how she confused it with another liquid medication. Quantity values on the two bottles somewhat matched. When V18 (LPN) wanted to record the given amount of 2.5 milliliters, she realized remaining amount recorded on the controlled drug administration sheet was completely different, so she tried to match the number from previous sign out even though V18 (LPN) saw that there was less medication in the bottle than recorded. Surveyor asked what should V18 (LPN) have done when she noticed the discrepancy, V18 (LPN) said that when she saw the discrepancy, she should have checked the bottle to verify the difference. V18 (LPN) also said that she was trained pertaining to controlled medication administration upon hiring, which was in January 2021 and most recent in-service regarding nursing skills was in March 2023. On 5/17/2023 at 12:27 PM Surveyor interviewed V19 (Licensed Practical Nurse), V19 (LPN) stated, I don't know what happened. I always give R129 2.5ml of the schedule II controlled pain medication each morning. I don't remember how much was left in the bottle when I gave it last time (on 05/06/2023) but there are other nurses working on the floor. Surveyor asked what should be done if controlled medication discrepancy is discovered, V19 (LPN) said that if there is a discrepancy, the nurse should call another nurse or Director of Nursing to verify and then both have to count and sign. Pharmscript Controlled Substance Storage policy reads in part, Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, Director of Nursing notifies the administrator and consultant pharmacist immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 7 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 pharmacy medication storage and labeling policy and facility medication pass policy by not noting and implementing open date labels and failing to refrigerate new medication requiring refrigeration before opening. This applies to 6 of 85 (R22, R27, R61, R70, R76, and R121) residents' medications in three of five medication carts and one of one medication storage rooms during the medication storage and labeling task. Findings Include: On 05/16/23 at 10:10 AM Surveyor conducted inspection of the facility medication storage room. Surveyor observed opened and undated medication for: R61 - Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-injector 2 MG/3ML (Semaglutide) - no open date On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. Surveyor observed opened and undated medications for: R22 - Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) - no open date R61 - HumaLOG Solution 100 UNIT/ML (Insulin Lispro) - no open date R76 - Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine)- no open date On 05/16/23 at 10:56 AM Surveyor conducted inspection of Unit D medication cart. Surveyor observed opened and undated medications for: R70 - Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH (Fluticasone-Umeclidin-Vilant) - no open date R121- HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) - no open date On 05/16/23 at 11:47 AM Surveyor conducted inspection of Unit B medication cart. Surveyor observed unopened and inappropriately stored medication for: R27 - Latanoprost Solution 0.005 % eye drops - new, unopened, should be refrigerated when new and unopened On 5/17/2023 at 10:13 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, You need to know the expiration date because medications like insulin are good for only 27 days. It is because of the effectivity of the medication. Other medications than insulin may also be no longer effective, that's why it's important to document expiration date upon opening. Facility Medication Pass policy dated 03/28/2023 reads in part, It is the policy of the facility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 8 of 9 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 145860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of Skokie, The 9000 LA Vergne Avenue Skokie, IL 60077 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 adhere to all federal and state regulations with medication pass procedures. Insulin vials are to be discarded within 28 days after opening. Pharmscript Medication Label policy dated 11/19/2018 reads in part, Each prescription medication label includes Beyond Use (or expiration) date of mediation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 9 of 9