Inspection·August 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few compression and fusion followed by lumbar compression and fusion, chronic left hemiplegia. Goal: R1 will not sustain serious injury through the review date. Interventions: Provide visual prompts call don't' fall in resident room. Apply bilateral floor mats when resident is in bed. Bed in lowest position. Falling leaf sign in place. Keep items, water, etc. in reach. Remind resident to call for assistance when ambulating. On 8/2/24 at 11:15 AM, V2 stated, She (R1) is confused and has psych affective disorder and a history of fabricating stories, history of verbal aggression towards staff. She fabricates like answering call lights. She is interviewable and she is here for fracture before, and she had neck fracture from upon admission She said she was going to go to the bathroom but then she was attempting to try to get out of bed and kicked the stand for the bedside table and bumped with her knee. She did not use the call light and she went back to bed. Surveyor asked if the resident is confused how V2 expected for the resident to use a call light to get assistance. V2 had no response. Surveyor asked if it was possible a bump into a side table could sustain an injury such as a knee fracture. V2 indicated that was what was reported to him. On 8/2/24 at approximately 12:30 PM, V3 (ADON) called V5 (night nurse) to speak to the surveyor. V3 remained in the room to witness the conversation. V5 stated, R1 was sleeping throughout the night without complaint and then early in the morning she was asking for ice pack while I was passing my morning medications. I assessed her knee and there was no swelling in sight, and she asked for stronger pain medications. I gave her the ice pack and put it on her knee. I asked do you need pain medication. That was all she told me and there was no swelling or any injury I saw. I did not even know she fell, and she did not get up at all during my shift because normally everyone is sleeping so she did not fall during my shift. I assessed her knee because I am feeling something on her knee, but I did not write any of this down, but I should have. That is a mistake on my part. V5 stated, She (R1) said my knee is pain and sometimes she has an attitude, but she did not say to look at her knee. When she asked for the ice pack, she said she was feeling pain on her knee, so I asked her what's really going on with her knee. She just said to give me ice pack for swelling. She did not allow me to look at her knee. She just said she has pain. Surveyor asked if V5 did any assessment or palpating (examine by touch) of her knee. V5 said, Yes I palpated her knee but like I said I didn't write this down. Surveyor reminded V5 earlier she indicated the resident didn't allow her to touch her knee but now she's claiming she palpated her knee. V5 said, I did assess her (R1) knee and all she tell (sic) me about the knee. She told me all I need is an ice pack, that is the reason. Surveyor asked if she knew how R1 got injured. V5 stated, I don't know what happened with the knee. She did not explain to me what happened, but I should have asked her, so I did not get part of the story. I didn't know what happened to her that night. I don't know anything. I was the only nurse night and there is no manager on duty, and I did not endorse this incident to the next shift. After this interview, surveyor asked V3 (ADON) whether V5 night shift nurse assessed R1's knee or just gave her the ice pack without looking at the knee, V3 said, I don't think she looked at the knee at all. Surveyor asked when the facility discovered R1's knee injury, V3 stated, It was the following shift on Monday 7/8/24 after V5 gave the ice pack to the resident. The nurse V8 (RN) assessed R1's knee because she complained of pain and didn't want to get up for therapy so that was when V8 assessed the resident and called the doctor for a stat x-ray. We tried to trace back how she may have gotten the injury. She was showered the day before on 7/7/24 by V7 (CNA) but there was no report of any fall. Then the DON (V2) investigated it and determined she may have hit her knee on the bedside table. Surveyor asked if the facility determined whether the resident sustained the fracture during transfer, during showering, or hitting of the bedside table. V3 indicated, their investigation was inconclusive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145630 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 145630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of R1's MDS (minimum data set) dated 4/29/24 prior to the incident showed R1 requiring substantial assistance with showering, and tub/shower transfers however was only provided this task by only one staff member V7. V7 (CNA) could not be reached for interviews after several attempts to call from surveyor and from administration. On 8/2/24 at approximately 1:00 PM, surveyor returned to R1's room. Outside the room were 3 names of residents residing in the room, one of which was R1 who was in bed 1. There were no indications or symbols denoting R1 was on any falling leaf program to designate the resident as being at risk for falls. As surveyor entered, the room remained darkened and with the resident in the same position and with one floor mat on the right and a folded up fall mat to the left and away from the bed. The call light remained above R1's head and away from her reach and there were no signs for the resident to prompt resident to call don't fall as indicated in the resident's plan of care. V3 (assistant director of nursing) was shown what surveyor had observed. V3 indicated the folded up mat should have been unfolded and extended across the floor to protect the resident from falling. V3 indicated she did not know where the signs to prompt R1 to call before she fell and acknowledged the call light was not within reach of the resident. V3 proceeded to move the bedside table atop the right floor mat which could have been an accidental hazard and had no purpose beside the resident as it had no other items on it the resident could have used. Surveyor asked V3 if she could ask R1 about her knee and to see if we could examine the injury. With R1's permission, V3 removed the right leg brace and showed the surveyor the fractured knee. V3 said there was some swelling remaining and slight bruising in the center of the knee area. Surveyor and V3 asked the resident if she was in any pain. R1 stated, I'm in pain when I'm moved. R1 went on to describe how she fell and said it may have occurred when V9 (CNA) transferred her to her wheelchair or when she was showered by V7 (CNA) but could not recall anymore. Surveyor asked when she started feeling the pain on her knee. R1 stated it was when she asked the night shift nurse for ice to put on her knee when she noticed there may have been a problem with her knee. Surveyor asked if V5 (night nurse) gave her the ice and if the nurse looked at her knee to assess her pain. R1 stated, No, she never looked at my knee. She just gave me the ice and left. Surveyor asked if V5 inquired why R1 needed the ice pack. R1 stated, No. She seemed very busy, and I saw her only once at the end of her shift. V6 (CNA) statement taken by V2 (DON) pertaining to R1's fall incident of 7/7/24 reads in part, Around 4:30 AM when I was changing R1 diaper she asked for an ice pack for her knees. She said she bumped her leg on the side table when she was going to get up to go to the bathroom. I gave her the ice pack from nurse (V5) and nurse looked at her right knee, but it wasn't swollen or anything. She (R1) said she just went on her briefs because she no longer wanted to get up after that just happened. She went back to sleep, and she did not wake up again for the rest of my shift. V6 (CNA) could not be reached for interviews after several attempts to call from surveyor and from administration. On 8/2/24 at approximately 2:15 PM, V8 stated to surveyor, The resident (R1) told me she doesn't want to get up because she was supposed to be getting physical therapy and so didn't want to get up and said her legs hurt. I checked and noticed her right knee was swelling. I gave her Tramadol (for pain) and she requested an ice pack. This was probably Monday around 9:30 in the morning and I called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145630 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 145630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the NP right away to get an order for X-ray and the results were positive for a fracture, so we sent her out to the emergency room, and she was admitted for a knee fracture but no surgery just immobilizer. Hospital records authored by V10 (hospitalist doctor) reads in part, R1 is a [AGE] year old who presented to the emergency room with chief complaint of fall. Patient is alert and oriented to person, place, and year. Patient says she had a quarrel with a staff member, and they moved the wheelchair causing patient to fall at nursing home. Patient is not sure which day the fall happened. Per ER note, patient fell in the shower. She complaint of neck pain which says is worse, also complaints of low back pain and abdominal pain. CT knee without contrast result date 7/8/24 clinical indication: Right knee fracture. There is a moderate lipohemarthrosis decompressing into a 2 cm Baker's cyst. There is mildly scattered superficial subcutaneous edema. Impression: 1. Acute intra-articular medial tibial plateau fracture. Fall prevention policy and procedures dated 11/21/2017 reads in part, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Fall/safety interventions may include: The resident's personal possessions will be maintained within reach when possible. These items include tissues, water, drinking glass and phone. Assistive devices such as walkers and canes will be placed within reach of those residents who have physician's orders to ambulate independently. The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance with the resident's desire and the plan of care. Call lights are answered promptly. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Transfer conveyances shall be used to transfer residents in accordance with the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145630 If continuation sheet Page 4 of 4