Health inspection·October 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Blood Pressure) check every 15 mins. V6 left the chair side and after few minutes R1 was complaining again with cramping on the legs. As soon as R1 verbalized cramping, R1 stood up and lost his balance and fell on the floor. R1 was in V6's clear view. V6 stated she was at the nurse's station, approximately 10 steps away from R1. Per V6, regarding the fall on 8/1/24, R1 complained of cramping. V6 stated they already knew R1 fell the last time R1 was in dialysis, so we went to R1 as R1 was trying to stand up to make sure R1 wouldn't fall again. R1 was trying to stand up at the time. All three-dialysis staff were surrounding R1. R1 started shouting ‘back off' and was motioning of pushing us away. We explained to R1, we just wanted to make sure he is safe because he fell in treatment before. R1 eventually was able to sit down. We gave him his space. V6 turned around and heard a thud noise while walking away and halfway to the nurse's station. There was blood on the bottom lip. We helped him untangled the lines and R1 was able to get back on the chair with stand by assist. On 10/10/25 at 10:19AM V3 (Restorative Nurse/Fall Coordinator) stated when an incident happened, we made sure we did the investigation right away to find the root cause. Post fall huddle. New intervention will be added in the care plan. V3 stated R1 had a fall incident on 7/30/25 at 10 am, fell towards the end of dialysis treatment. V3 stated R1 reported R1 was having cramps in his leg. R1 needed to get up and lost his balance. There was dialysis staff present when the incident happened. Root cause for this fall was non complainant and behavior of R1. Per V3, the fall on 8/1/25 at 10AM, R1 lost his balance and fell on the floor. V3 stated this happened again in the dialysis unit. R1 initially was moderate risk for fall upon admission and became high risk for fall after the fall on 7/30/25. Intervention is to reeducate about safety reminder not to get up by himself.Record reviewed: R1 has a care plan for at risk for falls gait/balance problems secondary to chronic osteomyelitis right ankle and foot, type 2 diabetes, CKD (Chronic Kidney Disease), CHF (Congestive Heart failure), BPH (Benign Prostate Hyperplasia) and Glaucoma, with initial date of 7/17/25 and revision date of 7/27/25. R1's interventions initiated 7/18/25 and revision on 8/4/25, reads: 7/30/25: Reinforce education about safety reminder not getting up by himself. Initiated 7/18/25 and revision on 8/4/25. 2. R2 is a [AGE] year-old female resident. admitted in the facility on 6/11/22 with diagnoses of but not limited to: Type 2 diabetes, Alzheimer, dementia, hyperlipidemia, iron deficiency, hypertension, age-related osteoporosis, osteoarthritis right hip unilateral osteoarthritis right knee, vitamin D deficiency, anorexia nervosa, lack of coordination. BIMS score of 4 (severe cognitive impairment).R2's Fall incident Report dated 9/28/25, reads in part: While writer is giving report to the CNA, noted R2 walking towards to this writer with increased agitation when the writer turned around, observed R2 on the floor in prone position wearing improper footwear. Resident description: I tripped on my slippers.R2 with MORSE Fall Scale Evaluation (Fall Risk Assessment) dated 5/19/25 as high risk, score of 61; Post fall incident MORSE Fall Scale Evaluation score of 31 as Moderate Risk, dated 9/28/25. On 10/10/25 at 11:30AM, V3 (Restorative Nurse/Fall Coordinator) stated R2 fell on 9/28/25, got up and started walking towards the staff and lost her balance. The staff found R2 on the floor when they turned around in prone position. R2 was wearing slippers at the time. The root cause is not wearing the appropriate footwear and R1 should wear appropriate footwear when up from bed. R2 is usually up on the wheelchair. The incident happened in the hallway. R2 can ambulate and walk with supervision. Prone position, neuro check initiated. R2 can get up on her own, requires one staff assist, with walker with followed assist for safety.Record reviewed: R2 has a care plan for potential risks for falls related to/due to osteoarthritis bilateral lower extremities, with Past medical history: Alzheimer's/Dementia, seizures, hypertension, protein-calorie malnutrition, and Iron-deficiency anemia dated 6/14/22.R2 has an intervention of Ensure [NAME] is wearing appropriate footwear/nonskid socks when ambulating or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145630 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 145630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete mobilizing in wheelchair since 3/13/24. MORSE Fall Scoring High Risk 45 and higher. Moderate Risk 24-44.Fall prevention program with a revision date of 11/21/2017, reads in part: to ensure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each residence by assessing their risk of fall implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness.Default prevention program includes the following components: Methods to identify risk factors. Methods to identify resident at risk Assessment time frames. Use and implementation of professional standard of practice. Immediate change in intervention were successful. Notification of decision, family and legal representative. Communication with direct care staff member. Documentation requirements. Care plan incorporates: Identification of all risk and issues, addresses each fall, intervention or change with each fall as appropriate, preventative measure. Safety intervention will be implemented for each resident identified at risk.Accident incident report involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions.The director of nursing or designee is responsible for monitoring the fall prevention program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. In addition, director of nursing is responsible for informing the administrator of program analysis.Nursing personnel will be informed of residents who are at risk of falling. The fall risk intervention will be identified on the care plan.Footwear will be monitored to ensure the resident has proper fitting shoes and/or footwear is nonskid. Event ID: Facility ID: 145630 If continuation sheet Page 3 of 3