Health inspection·October 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Fall Prevention Program policy. The facility failed to prevent fall incident and failed to follow the care plan intervention for fall prevention for residents assessed to be moderate and high risk for fall. This deficient practice affects two residents (R1 and R2) of three residents reviewed for fall incidents.Findings Include: 1. R1 is a [AGE] year-old male resident admitted into the facility on 7/17/2025. R1 is with diagnoses of but not limited to: Chronic Osteomyelitis right ankle and foot, Absence of the Right Foot, Type 2 diabetes, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 chronic Kidney Disease, Congestive Heart Failure, Dependence on Renal Dialysis, Cerebral Vascular disease, Anemia and Abnormal Posture. BIMS (Brief Interview for Mental Status) score of 15 (Cognitively Intact).R1 had multiple fall incidents in the facility, dated 7/30/25 and 8/1/25 both in the dialysis unit.R1 with MORSE Fall Scale Evaluation (Fall Risk Assessment) dated 7/17/25 as Moderate Risk, score of 31; post fall incident MORSE Fall Scale Evaluation score of 65 as High Risk, dated 7/30/25. Fall incident report dated 7/30/25, reads in part: Informed by dialysis nurse, R1 fell on the floor towards the end of dialysis treatment, did not hit his head, no injuries, vital signs within normal limits. Resident description: I told the staff I was having cramps on my legs and I really needed to move. They were unable to assist me right away and I had to get up. I lost my balance and fell on the floor. Fall incident report dated 8/1/25, reads in part: Informed by dialysis nurse R1 fell on the floor, hit his head and busted his lip while trying to get up towards the end of his dialysis treatment. Resident description: I told the staff I was having cramps on my legs and I really needed to move. They were unable to assist me right away and I had to get up. I lost my balance and fell on the floor. Nurse Practitioner made aware with order to send to local hospital due to R1 hitting his head and busted lip. R1 strongly refused and verbalized Absolutely not. I'm fine. I don't want to go through all of that. I feel fine.On 10/10/25 at 10:54AM, V4 (LPN), Nurse of R1 on 7/30/25 and 8/1/25 on the skilled unit, stated dialysis nurse reported R1 fell towards the end of R1's treatment. Per V4, R1 reported R1 could not wait for them to disconnect him. They were all with other patients. R1 could not wait and R1 was inpatient. V4 reported on 8/1/25 that it was reported by the dialysis nurse that R1 was inpatient and wanted to get up right away. R1 fell and hit his head and busted his lip and had a skin tear on the lip. V4 was able to control the bleeding. V4 stated R1 refused to go to hospital and Neuro check initiated and no changes with R1. V4 reported V4 documented the same exact scenario on both falls because it was the same scenario that R1 could not wait and got up. V4 stated the verbatim documentation on both days just happened, and V4 stated V4 did not realize V4 documented it exact verbatim. On 10/10/25 at 12:46PM, V6 (RN) dialysis nurse stated on 7/30/25 fall incident, R1 was cramping and V6 went to R1's chair side to turn off the UF (ultrafiltration) to help ease off the cramping. Blood Pressure was ‘okay', alert and oriented. V6 left R1 chair side and programmed the BP Page 1 of 3 145630 145630 10/14/2025 Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714

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 145630 Page 2 of 3 145630 10/14/2025 Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 145630 Page 3 of 3