Inspection·April 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light dust on them. The residents' shared closet by the bathroom had sliding doors. One of the sliding doors was hanging by the top rollers and not secured on the floor. When surveyor tugged it, it swung outwards towards surveyor. The residents' shared bathroom had missing tiles at the bottom of the left wall. On 4/09/2025 at 1:27 PM, V27 (Housekeeping) stated staff are supposed to clean the residents' rooms daily including sweeping, mopping, and dusting. V27 stated V27 cleans the windows, but sometimes cannot clean them daily because it depends how many rooms V27 must clean for the day. When the facility assigns a lot of rooms to V27, V27 cannot clean the windows. On 4/09/2025 at 10:51 AM, the third floor's maintenance book did not have requests for repairs to R1 and R5's room for 2025. On 4/09/2025 at 11:01 AM, the fourth floor's maintenance book did not have requests for R6-R8's room for 2025. On 4/09/2025 at 11:31 AM, V17 (Respiratory Therapist) stated the second-floor construction has been going on for maybe six months. On 4/09/2025 at 2:32 PM, V28 (Maintenance Assistant) stated V28 was not aware that R1's side rail needed fixing until date of the survey. V28 stated staff will either write concerns on the maintenance logs on each floor, or verbally tell V28. V28 was also not aware of the furniture issues for R6, R7, and R8. When asked about the bathroom tiles and the missing panel/board behind R8's bed, V28 stated V28 had planned to replace bathroom trim and repaint the room, but had not gotten to them yet. On 4/10/2025 at 11:42 AM, V2 (Director of Nursing) stated the second floor is under construction and esthetically it doesn't look nice. When asked about the missing ceiling panels off the elevator, V2 stated if they're not working on it then it should be covered up. Regarding furniture repairs, V2 stated if something needs to be replaced or is damaged, the facility should try to do so as soon as they can. Staff should report the repairs to maintenance and if it's a quick fix, it should be fixed within that day. Facility's undated Maintenance Policy documents: Purpose: To ensure that the building (interior and exterior), grounds, and equipment are maintained in a safe and operable manner. It is the policy of the facility to provide a safe, accessible, effective and efficient environment of care that is consistent with its mission, services and law and regulations. Facility's Resident Rights policy (effective 8/23/2017) fails to include the residents' right to a clean, comfortable, and homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145484 If continuation sheet Page 2 of 5 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 145484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Chicago North 2451 West Touhy Avenue Chicago, IL 60645 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide timely incontinence care for two (R1, R5) out of seven residents reviewed for improper nursing care, with the potential to affect all the dependent residents V9 (Certified Nurse Aide) cares for in the facility. Residents Affected - Some Findings include: 1. R1's admission Record documents diagnoses of radiculopathy in the lumbar region, idiopathic progressive neuropathy, morbid obesity, osteoarthritis, abnormalities of gait and mobility, reduced mobility, and need for assistance with personal care. R1's 3/28/2025 Quarterly MDS (Minimum Data Set) assessment documents R1 is cognitively intact, and is dependent on staff for toileting. R1's Care Plan Report documents R1 has a functional deficit in bed mobility and ADL (Activities of Daily Living) self-care performance deficit due to generalized weakness, impaired gait/balance, pain, musculoskeletal impairment, impaired mobility, physical limitations secondary to mechanical fall, lumbar radiculopathy, and rotator cuff injury (revised 12/2024). It also documents R1 has alteration in musculoskeletal status related to lumbar radiculopathy and osteoarthritis (revised 1/03/2025). Intervention includes to Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance (initiated 1/03/2025). R1's Care Plan Report also documents R1 has bowel and bladder incontinence (revised 3/11/2025). Intervention includes to change R1's disposable briefs as needed (revised 12/30/2024). On 4/08/2025 at 12:13 PM, R1 stated about 1.5-2 weeks ago, V9 (CNA-Certified Nurse Aide) declined to change R1 until after lunch. R1 stated V9 did not want to change R1 before then. R1 stated V9 returned the following day, and told R1 and R5 the same thing. V9 was not going to change them until after lunch, unless it was an emergent situation like a bowel movement. R1 stated the CNAs will usually make the excuse of needing to pass the meal trays out first, then feed other residents, then collect trays, and then they can start changing the residents. R1 stated by that time, it's at least 1-1.5 hours until the CNAs change R1. R1 also stated in a separate incident last week, R1 needed to be changed around 9:00 PM. R1 notified V15 (CNA) and V15 stated will return later because V15 had to finish charting first. R1 stated V15 did not return, and R1 had to wait until the next shift at 11:00 PM. On 4/08/2025 at 1:35 PM, V9 stated V9 only rounds on the residents three times per shift (eight-hour shifts). V9 stated V9 will only change the residents a maximum of three times. When asked what happens if a resident has more than three incontinent episodes during the shift, V9 stated again no more than three. V9 continued with an example stating if a resident has diarrhea, V9 will only change them three times during the shift and no more. V9 stated, That's the only time we have out of the day. On 4/08/2025 at 1:48 PM, V10 (Nurse) stated if a resident has an incontinence episode and requests to be changed, staff should change them as soon as possible. V10 stated there is no limit to the amount the staff should be changing the resident. V10 stated if the resident is uncomfortable, then staff should change them. On 4/09/2025 at 3:05 PM, V15 (CNA) stated V15 usually takes care of R1 during the evening shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145484 If continuation sheet Page 3 of 5 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 145484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Chicago North 2451 West Touhy Avenue Chicago, IL 60645 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V15 stated a few incidents in which V15 had to change R1 right away during the start of shift (3:00 PM), because the day shift did not change R1 before leaving. V15 has found R1's incontinence product, linens, and whole bed soaked from not being changed promptly by the day shift staff. V15 stated, Since I've been a CNA, you can tell when someone hasn't been changed. V15 stated the sheets under are yellow or tan-brown color. The diaper is soiled, and the bed is soaked to the point that V15 is wiping and scrubbing the whole bed with a disinfectant wipe. V15 stated, That's why when I come in, I literally do [R1] first because the last shift didn't change [R1] right away or didn't change [R1] after lunch. [R1 will] be wet, wet and that's how it usually is. V15 stated R1 usually says that the morning staff do not change R1 more than once. On 4/08/2025 at 2:48 PM, V11 (CNA) stated R1 complains frequently about staff not changing R1 promptly after an incontinence episode. V11 stated R1 has also complained about staff informing R1 that staff will only change R1 once per shift. V11 stated, I think they [the residents] shouldn't have to wait because you wouldn't want to sit in your own pee. 2. R5's admission Record documents in part diagnoses of morbid obesity and diabetes. R5's 1/17/2025 Quarterly MDS assessment documents R5 is cognitively intact. R5's Care Plan Report documents R5 is at risk for alteration in skin related to limited mobility, diabetes mellitus type 2, vitamin D deficiency and vitamin B12 deficiency (revised 4/21/2024). It also documents R5 has ADL self-care performance deficit related to impaired balance (revised 4/21/2024). It also documents R5 has alteration in musculoskeletal status (last revised 4/21/2024). Intervention includes to Anticipate and need needs. Be sure call light is within reach and respond promptly to all requests for assistance (last revised 4/21/2024). It also documents R5 has a bladder and bowel incontinence related to activity intolerance (revised 4/21/2024). Intervention includes to change R5's disposable briefs as needed (revised 4/21/2024). On 4/08/2025 at 12:31 PM, R5 stated some CNAs are very vague. R5 stated CNAs will answer the call light and say they will be back, but some won't be back until hours later to change R5 and R1. R5 stated R1 (R5's roommate) is more dependent on the staff, and needs their help for a lot of things like toileting. On 4/10/2025 at 11:42 AM, V2 (Director of Nursing) stated the expectation is for staff to change and clean any resident when they need it. V2 stated the facility implemented no staff breaks within two hours before the end of their shift. Staff need to chart mid-shift and not wait until the end of shift to finish all their charting. V2 stated staff should be doing their last rounds within the last hour of their shift, meaning they're checking the rooms and changing the residents if they need it. Facility's Call Light policy (revised 2/02/2018) documents: Purpose: To respond to residents' requests and needs in a timely and courteous manner. Listen to resident's request. Do not make him feel that you are too busy to help. Facility's Incontinence Care policy (revised 4/20/2021) documents: Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145484 If continuation sheet Page 4 of 5 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 145484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Chicago North 2451 West Touhy Avenue Chicago, IL 60645 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 0677 Level of Harm - Minimal harm or potential for actual harm Facility's Resident Rights policy (effective 8/23/2017) documents: Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145484 If continuation sheet Page 5 of 5