Health inspection·June 1, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported R3 immediately got up from her wheelchair and aggressively went towards R4 and tried to grab her arm. A total of five staff members were interviewed and reported they have never witnessed R3 physically abuse R4. The report did not include any information that any other staff witnessed the incident or were present during the incident. R4's progress note dated 05/11/2023 5:59 PM documents resident was sent out after she got in physical fight with another resident and was admitted to the hospital for right upper arm contusion. R4's progress note dated 05/13/2023 documents the resident readmitted from the hospital with diagnosis of shoulder pain post altercation. R4's hospital report dated 05/13/23 documents her chief complaint as right shoulder pain after altercation; she presented to the hospital with right shoulder pain after being hit by another resident and reported feeling a bone on her shoulder that isn't usually there. She was admitted by the emergency room after concern for safety at nursing home. R4 reported taking Tylenol and tramadol with relief for chronic arthritis. For shoulder pain after altercation with chronic osteoarthritis, increased tramadol to QID (four times daily) as needed. R4's current physician orders document an active order effective 05/13/23 for 50mg of Tramadol tablet by mouth every 12 hours as needed for pain. On 05/31/22 from 11:47 AM - 12:10 PM V13 (Social Services Worker) reported R3's mood fluctuates from being joyous and happy to delusional. V13 stated R3 can lash out at a resident for no reason if they are talking to themselves and she believes they are talking to her. V5 (Social Services Director) stated she did observe in R3's admission paperwork that while in the hospital she was noted with exhibiting auditory hallucinations, aggravated aggression, and paranoia. V5 stated prior to being in the hospital before admission to the facility R3 had been noted to be at of halfway house. V5 stated per R3's admission paperwork while she was at the halfway house, she exhibited delusional, paranoid, and physically aggressive behaviors to her co peers. V5 stated typically when residents exhibit these behaviors they are monitored. V5 stated R3's triggers involve her delusions. On 05/31/23 from 12:30 PM - 12:45 PM R4 stated during the incident with R3 as she was heading to her room R3 suddenly lunged at her. R4 stated she raised her arm to protect herself and R3 grabbed down on her arm. R4 stated her right shoulder still hurts and they tell her it's ok but she feels its probably dislocated. R4 reported her pain in her right shoulder at a level 10. R4 stated she needs to use her hands and arms daily and it is difficult because of her shoulder pain. R4 stated although she has arthritis her pain seems worse after the incident where she was attacked by R3. R4 stated she is terrified of being at the facility because of the attack by R3 and is only remaining at the facility for the sake of her R7 (Family Member) On 05/31/23 from 12:51 PM - 1:00 PM V10 (Licensed Practical Nurse) stated he was R3's nurse on 05/11/23. V10 stated before the incident R3 was talking with him while he was working behind the nurses station. V10 stated R3 left the nurses station and began walking down the hallway towards the beverage cart. V10 stated he assumed R3 was going to get some tea from the cart. V10 stated he suddenly heard R3 yell from the hallway and upon responding to the yelling he then found R3 standing with her feet caught under R4's wheelchair and holding R4's arm. V10 stated R4 reported to him that R3 attacked her and R3 reported to him that while she was getting tea R4 called her profane names. V10 stated he did not see the interaction between R3 and R4 before or during the incident. V10 stated he only recalled a male dietary staff present during the incident and he did not witness any part of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 2 of 3 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 06/01/2023 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 0600 situation because his back was turned towards the residents. Level of Harm - Minimal harm or potential for actual harm On 05/31/23 from 2:00 PM - 2:33 PM V1 (Administrator) would not specify the level of supervision needed for R3 due to her delusional behavior and history of physical aggression with others as reported by social services. V1 stated the residents are monitored at all times by all staff and includes frequent rounding and staff assigned for frequent rounding, however it is not possible to observe them at every moment. V1 stated an incident can occur if a staff member looks away for even a second. V1 stated it is possible to adequately monitor residents while performing other duties by alternately observing the residents whereabouts and activity between performing work duties such as reviewing health records or passing medication. V1 stated the facility cannot provide one to one supervision for residents on a consistent basis. V1 stated she had not received any information that there were any dietary staff present during R3's incident of being physically aggressive with R4 on 05/11/23. V1 stated all the staff who were interviewed regarding the incident reported that they did not witness the incident. V1 stated due to R3 being delusional it's possible that her report of being verbally attacked by R4 did not occur. V1 agreed if there was a verbal altercation between R3 and R4 prior to the physical altercation as reported by V10 (Licensed Practical Nurse) that any staff present should have been alerted to the situation and intervened to prevent escalation. Residents Affected - Few The facility's abuse policy reviewed 06/01/23 states: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Abuse is willful infliction of mistreatment or injury. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical abuse includes but not limited to infliction of injury that occurs other than by accidental means and requires medical attention. Examples include grabbing and roughly handling. Prevention includes identify, correct and intervene in situations in which abuse is more likely to occur; deployment of sufficient staff to deal with behaviors in the units; monitoring of residents with needs and behaviors that might lead to conflicts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145860 If continuation sheet Page 3 of 3