Inspection·June 3, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident with assistance with ADLs (activities of daily living) in preparation for an outside medical appointment. This failure applied to one (R4) of three residents reviewed for assistance with ADLs. Residents Affected - Few Findings include: R4 is a [AGE] year-old resident admitted to the facility on [DATE]. R4 has medical diagnoses that include: Chronic Kidney Disease (Stage 4), Anemia, Congestive Heart Failure, Type 2 Diabetes, Osteoarthritis, Long Term use of Insulin, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and Adjustment disorder with anxiety. R4's most recent MDS (Minimum Data Assessment) dated 04/23/24 documents that R4 has a BIMS (Brief Interview of Mental Status) score 15 (intact cognition) and has mobility impairment on both sides. R4's Current Care Plan includes the following Special Instructions: TRANSFERS: DEPENDENT X2 STAFF ASSIST WITH MECHANICAL LIFT Focus renal insufficiency related to Chronic Kidney disease with intervention of Assist with ADLS and ambulation as needed. Focus ADL Self Care Performance Deficit related to hemiplegia/weakness, pain, poor endurance, decreased safety awareness, and visual impairment with interventions of encourage R4 to use call bell for assistance. 06/01/24 at 3:33PM, R4 stated that she missed her opthalmology appointment on 4/4/24 because the CNA assigned to her did not get her ready on time. R4 added that by the time staff figured out she was supposed to be leaving for an appointment, transportation came and left. R4 said that now she can't get another appointment until August 2024. R4 confirmed that she needs help with dressing and bathing as she cannot do it herself. Review of nursing schedule for 4/4/24 documents that V10 (CNA) was assigned to R4 for that day. 06/01/24 at 4:45PM, V2 (Director of Nursing) confirmed that V10 no longer works at the facility and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145662 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 145662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Niles 8333 West Golf Road 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)