Inspection·September 13, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm On 9/13/24 at 1:22 PM, R2 was dressed and up in her motorized wheelchair. R2 said they got her up about 1:15 PM and at least she was up in time to go to the activity at 2:00 PM. R2's Minimum Data Set, dated [DATE] shows R2 is cognitively intact and is dependent on staff for bed to chair transfers. Residents Affected - Few R2's Care Plan shows R2 requires a full body lift for transfers and is dependent on two staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145662 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 145662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to ensure staffing was sufficient to provide care for residents for 3 of 8 (R1, R2, R3) residents reviewed for staffing in the sample 8. Residents Affected - Few The findings include: On 9/13/24 there were two nurses and 2 Certified Nursing Assistants (CNA) observed working on the second floor for 37 residents. On 9/13/24 at 9:39 AM, R1 said they are forever short staffed. It doesn't matter what shift. Only two Certified Nursing Assistants (CNA) on the floor for over 30 something residents. Some days especially on the weekends, they don't get me out of bed because they are working short staffed. On 9/13/24 at 9:54 AM, R2 was in bed, dressed in a patient gown. R2 said she is waiting for the staff to help her get dressed and out of bed and into her chair. R2 said she likes to get up usually between 10:00 to 11:00 AM. R2 said it takes two staff and the mechanical lift machine to get her out of bed. R2 said this week and last week on day shift there has only been 2 CNA for the day shift. R2 state Saturday I didn't get out of bed at all because there wasn't enough staff on days and then by the time the afternoon staff came it was already almost dinner and I go back to bed right after dinner, so it was like why bother. The CNAs working are good but they are not super people. On 9/13/25 at 11:27 AM, R2 was still in bed waiting for staff to get her up. On 9/13/24 at 12:05 PM, R2 was still in bed and was eating her lunch. R2 stated They are really dragging their feet about getting me up today and I'm a little upset about it. They had to get the dialysis residents up first, so they are the priority. On 9/13/24 at 1:22 PM, R2 was dressed and up in her motorized wheelchair. R2 said they got her up about 1:15 PM and at least she was up in time to go to the activity at 2:00 PM. On 9/13/24 at 10:15 AM, R5 stated We need more CNAs, like today they are short, some staff called off and I overheard them say - they better replace the staff because state is here but if you guys are not here, they won't do anything. The CNAs work very hard, and they need help. On 9/13/24 at 9:58 AM, R3 was lying in bed. R3 said that his catheter is leaking, and he was last changed around 5:00 AM. At 10:26 AM, V7 (Registered Nurse) went to R3's room to observe his catheter. R3's incontinence brief was wet. R3 stated, How come this is wet? when he touched the top of his brief. V7 then told R3 that she would have the Certified Nursing Assistants (CNAs) come in and change him. V7 exited the room and continued with passing medications. On 9/13/24 at 10:30 AM, V5 said, We are doing him next. We have not gotten to him yet today since there is only two of us and I was here for the first two hours of my shift by myself. V5 said that his shift starts at 7:00 AM. At 11:00 AM, V5 said that resident should be checked every two hours to see if they need to be changed. On 9/13/24 at 10:39 AM, V4 and V5 (CNAs) provided incontinence care to R3. R3's incontinence brief (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145662 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 145662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 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)

F 0725 was wet and had stool present. Level of Harm - Minimal harm or potential for actual harm On 9/13/24 at 10:35 AM, V4 (CNA) said there is usually 3 CNAs on day shift, but there was a call off and there was only 2 CNA's today. V4 stated there are 36 residents for 2 CNA's and it's a struggle to get people up when residents require two person transfers to get out of the bed and then we have to get showers done. Residents Affected - Few On 9/13/24 at 11:05 AM, V5 CNA said on Monday, Wednesday, and Friday some residents have dialysis and have to get up and get downstairs, so they are the first priority. V5 said dialysis days are hard but they try to do their best. On 9/13/24 the second floor was observed from 11:04 AM to 12:15 PM. V4 and V5 were observed transferring resident with mechanical lifts which required both of them in the resident rooms, transporting residents in the elevator down to dialysis (one resident required both staff to push the resident in the chair and to push the oxygen concentrator) and then scrambling to pass the noon meal trays to the residents. When the CNAs left to transport the resident's downstairs to dialysis there were no CNAs left on the floor. The resident meal trays were delivered at 11:25 AM, but V4 and V5 were not able to start passing the trays until 11:45 AM and were finished delivering trays at 12:10 PM. At 12:15 PM, V5 said he needed to help a resident eat and then needed to get residents up still. On 9/13/24 at 12:48 PM, V9 (Scheduler) said the second floor is supposed to have 3 CNAs on days and PM shifts. V9 stated second floor is our heavy floor. There are heavy residents (dependent on staff) that take two people to care for. Today there was a call off and I was unable to find coverage. The facilities Grievances show two concerns in August 2024 and one concern already in September 2024 regarding call light response time and activity of daily living care. The facility's staffing schedule for today 9/13/24 shows there are two CNAs for second floor day shift. The staffing schedule from 8/13/24 to 9/13/24 (including 8/24/24) shows out of the last 32 days, 19 days only had two CNAs working on second floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145662 If continuation sheet Page 4 of 4