Health inspection·November 7, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's lab result reported on 10/22/23 showed she had a UTI (Urinary Tract Infection). R1's urine was turbid in color; contained leukocytes and blood; and greater than 100,000 CFU/ml Staphylococcus epidermidis. R1's Progress Notes showed on 10/6/23, R1 was being physically aggressive towards staff and refusing to leave a male resident's room, stating they wanted to be left alone. These notes showed on 10/13/23 R1 was pacing back and forth on the unit and stated, I'm done with all of you. Done. Shame on all of you. R1 was administered a one time dose of anti-anxiety medication (Ativan). On 10/14/23 R1 was agitated and verbally aggressive towards staff. Another one time dose of Ativan was obtained and given. On 10/17/23 R1 had increased confusion and agitation. The doctor was called and new orders for a urinalysis were obtained. On 10/22/23 R1 was noted with agitation towards other residents and staff. During attempts to redirect, R1 gets more loud and angry. The interventions are not effective and resident does not understand what staff is trying to say to her. R1 eventually settles down. On 10/24/23, R1 is agitated, aggressive toward staff members and unable to be redirected. R1's 10/19/23 Psych Consult showed nursing had reported R1 had increase in anxiety, agitation, and verbal aggression. This document showed R1 was close to a male resident and when staff attempt to redirect or keep physical distance between them, the resident gets very agitated. R1 was irritable, anxious, and angry. R1 had no self-awareness of her illness and tends to blame others. R1 had disorganized thought processes and speech. R1 had poor judgement, impaired memory, and poor insight. On 11/3/23 at 12:37 PM, V9 (LPN - Licensed Practical Nurse) said she was familiar with R1. V9 said R4 was admitted to the memory care unit in September 2023. V9 said R1 and R4 began talking and eventually they developed a friendship. V9 said she thinks she left a voicemail for V6 (R1's State Guardian) about the urinalysis results. On 11/3/23 at 12:51 PM, V7 (LPN) said R1 was talkative and able to ambulate independently, in the memory care unit. V7 said R1 was getting more agitated, but did not remember the exact date or details. V7 said she called the physician and obtained an order for a urinalysis. V7 stated, I believe she had been started on antibiotics for a UTI. I was her nurse the day she transferred to another facility (10/24/23), but they moved her out of the unit. In report they said on night shift, R1 was in R4's room and she thought she was his wife. They separated the residents and moved R1 out of the unit in the morning. I remember [V5] asking me to prepare a one time dose of Ativan for R1. I guess she didn't like the new room and was agitated. I didn't call [V6 - R1's State Guardian] about her transfer to another facility. [V5 - Memory Care Director] said she was going to email him. I've talked to [V6] before, but not for [R1]. There is a number to call in the chart for [V6]. V7 said a change in behavior or condition should be reported to the State Guardian. V7 stated, It's important they know what is going on. On 11/3/23 at 1:35 PM, V5 (Memory Care Director) said she is a CNA (Certified Nursing Assistant) and has been the Memory Care Director for 2 years. V5 said R1 was admitted in March 2023. V5 said when R4 arrived in September 2023, he clicked with R1. V5 said R1 would go in R4's room and become agitated with staff would attempt to redirect her out of R4's room. V5 said R1 believed R4 was her husband. V5 said R1 got in her face, and was fixated on R4. V5 said they tried to move R4 out of the memory care unit, but he was too high of an elopement risk and had to move him back into the unit. V5 said R1 and R4 found each other again. V5 said R1's fixation on R4 was a new behavior for her, but she did not notify V6 (R1's State Guardian). V5 said the nurses should have notified V6 of the change in R1's behaviors. V5 said on 10/24/23 R1 was found in R4's room and she became aggressive with staff when they tried to get her out of R4's room. V5 said they tried to move R1 out of the memory care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145872 If continuation sheet Page 2 of 6 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 145872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Long Grove Rehab &hc Ctr 2308 Old Hicks Road Long Grove, IL 60047 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unit, but the move was unsuccessful. V5 said they tried 2 different units and R1 was not tolerating the change. V5 said she did not notify V6 about the involuntary transfer until 10/25/23 (the next day), via email. V5 said she tried calling, but the voicemail was too long. On 11/7/23 at 12:48 PM, V2 (DON - Director of Nursing) said a change in condition should be called to the State Guardian or resident representative as soon as possible. V2 said a change of condition would include new or escalating behaviors; increased or new onset of confusion; and unplanned weight changes. V2 said V6 (R1's State Guardian) should have been notified of R1's fixation on R4. V2 said the facility is responsible for keeping them informed and updated on the resident's care and condition. The facility's Change of Condition (Resident) Policy dated 9/20 showed, Purpose: To ensure that the resident's physician/physician on call/NP and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145872 If continuation sheet Page 3 of 6 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 145872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Long Grove Rehab &hc Ctr 2308 Old Hicks Road Long Grove, IL 60047 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify R1's State Guardian and the Ombudsman of R1's involuntary transfer for 1 of 3 residents (R1) reviewed for discharge/transfer in the sample of 3. The findings include: On 11/3/23 at 11:32 AM, V6 (R1's State Guardian) said on 10/25/23 he received an email from V5 (Memory Care Director) that R1 had been transferred to another facility on 10/24/23. V6 said the email on 10/25/23 was the first contact he has had with the facility since July 2023. V6 said V5 told him that R1 had become fixated on a male resident, who was 10 years younger and had higher cognitive function, in the memory care unit. V6 said V5 reported that R1 would become physically and verbally aggressive with the facility staff when they would try to separate R1 and the male resident. V6 said V5 reported this issue started around 10/13/23. V6 stated, He asked the facility why [R1] was moved without consent or discussing the issues with him. I explained that our office has someone available 24/7. [V5 - Memory Care Director] said she was busy with [R1]. I asked them why they didn't try PRN (as needed medications), rather than moving her. Apparently they tried to move [R1] out of the unit, but she was running out of the building. That's when corporate made the decision to move [R1] to another facility. They are lucky that [R1] is doing well at the new facility. Her guardianship will need to be transferred to the regional office, nearest the new facility. So many things could have been done before moving her. If the facility would have reported her fixation on the male resident and her increased behaviors, then I would have welcomed a Care Plan Meeting. I did not receive an invite to the Care Plan Meeting on 10/20/23. Communication has been an issue with the facility. I would have expected a call when the behavior changes started. They are required to notify me and obtain consent for changes in treatment and transfers/discharges. If they would have notified me of the need to transfer, then I would have discussed the move with the ward, and tried to reach the best possible outcome for [R1]. V6 said he reviewed R1's case notes and there was no evidence of the facility calling regarding R1's behavioral changes between 10/13/23 and 10/24/23. R1's Facesheet dated 11/7/23 showed R1 was admitted to the facility on [DATE] and had diagnoses to include hypertension, dementia and anxiety. R1's facility assessment dated [DATE] showed she had severe cognitive impairment and had no behaviors. R1's Office of State Guardianship document was dated 3/1/23. R1's POS dated 11/7/23 showed she had orders on 10/14/23 and 10/24/23 for one time doses of ativan (anti-anxiety medication); and an order to transfer to another facility on 10/24/23. R1's Progress Notes showed on 10/6/23, R1 was being physically aggressive towards staff and refusing to leave a male resident's room, stating they wanted to be left alone. These notes showed on 10/13/23 R1 was pacing back and forth on the unit and stated, I'm done with all of you. Done. Shame on all of you. R1 was administered a one time dose of anti-anxiety medication (Ativan). On 10/14/23 R1 was agitated and verbally aggressive towards staff. Another one time dose of Ativan was obtained and given. On 10/17/23 R1 had increased confusion and agitation. The doctor was called and new orders for a urinalysis were obtained. On 10/22/23 R1 was noted with agitation towards other residents and staff. During attempts to redirect, R1 gets more loud and angry. The interventions are not effective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145872 If continuation sheet Page 4 of 6 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 145872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Long Grove Rehab &hc Ctr 2308 Old Hicks Road Long Grove, IL 60047 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and resident does not understand what staff is trying to say to her. R1 eventually settles down. On 10/24/23, R1 is agitated, aggressive toward staff members and unable to be redirected. R1's 10/19/23 Psych Consult showed nursing had reported R1 had increase in anxiety, agitation, and verbal aggression. This document showed R1 was close to a male resident and when staff attempt to redirect or keep physical distance between them, the resident gets very agitated. R1 was irritable, anxious, and angry. R1 had no self-awareness of her illness and tends to blame others. R1 had disorganized thought processes and speech. R1 had poor judgement, impaired memory, and poor insight. R1's Care Plan dated 3/8/23 showed, [R1] has a state guardian and full code at this time . Interventions/Tasks: .Collaborative relationships will be utilized in coordination of resident's care. Legal paperwork will be collected and filed . R1's EMR (Electronic Medical Record) did not have a Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form. The facility did not complete this required form. On 11/3/23 at 1:06 PM, V11 (Ombudsman) said he was not notified of R1's Involuntary Transfer. V11 said once the Ombudsman is notified, then they will reach out the resident or resident representative and the facility. On 11/3/23 at 12:51 PM, V7 (LPN) said R1 was talkative and able to ambulate independently, in the memory care unit. V7 said R1 was getting more agitated, but did not remember the exact date or details. V7 stated, I was her nurse the day she transferred to another facility (10/24/23), but they moved her out of the unit. In report they said on night shift, R1 was in R4's room and she thought she was his wife. They separated the residents and moved R1 out of the unit in the morning. I remember [V5] asking me to prepare a one time dose of Ativan for R1. I guess she didn't like the new room and was agitated. I didn't call [V6 - R1's State Guardian] about her transfer to another facility. [V5 - Memory Care Director] said she was going to email him. I've talked to [V6] before, but not for [R1]. There is a number to call in the chart for [V6]. On 11/3/23 at 1:35 PM, V5 (Memory Care Director) said she is a CNA (Certified Nursing Assistant) and has been the Memory Care Director for 2 years. V5 said R1 was admitted in March 2023. V5 said when R4 arrived in September 2023, he clicked with R1. V5 said R1 would go in R4's room and become agitated when staff would attempt to redirect her out of R4's room. V5 said R1 believed R4 was her husband. V5 said R1 got in her face, and was fixated on R4. V5 said they tried to move R4 out of the memory care unit, but he was too high of an elopement risk and had to move him back into the unit. V5 said R1 and R4 found each other again. V5 said R1's fixation on R4 was a new behavior for her, but she did not notify V6 (R1's State Guardian). V5 said the nurses should have notified V6 of the change in R1's behaviors. V5 said on 10/24/23 R1 was found in R4's room and she became aggressive with staff when they tried to get her out of R4's room. V5 said R1 and R4 were getting too close. V5 said they tried to move R1 out of the memory care unit, but the move was unsuccessful. V5 said they tried 2 different units and R1 was not tolerating the change. V5 said she did not notify V6 about the involuntary transfer until 10/25/23 (the next day), via email. V5 said she tried calling, but the voicemail was too long. V5 stated, Now I have the after hours number to call, but we didn't have that before this happened. V5 said she did not notify the Ombudsman of R1's involuntary transfer. On 11/3/23 at 2:17 PM, V1 (Administrator) said she did not personally notify anyone (V6 - State Guardian or V11 - Ombudsman) of R1's involuntary transfer. V1 stated, Chaos was happening. I called the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145872 If continuation sheet Page 5 of 6 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 145872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Long Grove Rehab &hc Ctr 2308 Old Hicks Road Long Grove, IL 60047 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few office and said I needed him (V6) immediately and I was sent to the voicemail. The resident was in crisis and the voicemail was too long. I told [V5 - Memory Care Director] to try calling him (V6) again. We send out referrals to some of our sister facilities, but at this time [R1] was refusing to come back in the building. We decided to make the emergency transfer for her safety. [R1] was becoming more intimate with [R4] and she isn't capable of giving consent. We made the decision for her safety. I was not aware that I needed to notify the Ombudsman of [R1's] transfer. The facility's Involuntary Discharge or Transfer Policy dated 11/2017 showed, Policy: The facility will provide proper procedure and notification of an involuntary transfer or discharge pursuant to the regulations of the Health Care Financing Administration for States and long term care facilities, 42 CFR 483.15 (federal regulations); and State rules and regulations. Procedure: .Notification and Documentation: 2. Residents and their Representative(s) must be notified of transfer and the reasons for transfer. This notice must be provided in writing thirty (30) days prior to transfer or, as soon as practicable . The transfer or discharge shall be discussed with the resident, resident's representative, and person or agency responsible for the resident's placement in the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145872 If continuation sheet Page 6 of 6