Health inspection·December 16, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 follow their call light policy and answer residents' call light in a timely manner for three (R1, R3, and R4) residents out of four residents reviewed for call lights in a total sample of four residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. Residents Affected - Few Findings include: On 12/15/2024, 9:29 AM, V5 (Certified Nursing Assistant) states that currently there are two certified nursing assistants working on this floor and one nurse. V5 states that there are approximately 22 residents on this floor. On 2/15/2024, 9:44 AM, R1 is laying down on her bed, head of her bed slightly elevated, and in no apparent distress. R1 is wearing black sunglasses. R1's call light is within reach. R1 reports that she has waited several hours to be changed. R1 states that sometimes staff take long to answer her call lights. R1 states that it takes 2 hours for someone to answer her call light. R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R1 is cognitively intact. 12/15/2024, 9:57 AM, R3 is standing up, using oxygen via nasal cannula, with a steady gait. R3 states that she observes staff taking a long to attend to R1. R3 states that staff can take up to one hour before they answer R3's bedroom call light. R3's MDS/Minimum Data Set, dated [DATE], documents that R3 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R3 is cognitively intact. 12/15/2024, 1:25 PM, R4 is sitting in his wheelchair in his bedroom, R4 is alert and responsive. R4 states that he does need assistance with staff to change his incontinence briefs. R4 states that he does utilize his call light to call for assistance. R4 states that he has waited more than 2 hours for his call light to be answered. R4 states that no other staff help answer call lights, and usually just the nursing aids. Sometimes the nurses answer the call lights. R4's MDS/Minimum Data Set, dated [DATE], documents that R4 has a BIMS/Brief Interview for Mental Status score of 14/15, indicating that R4 is cognitively intact. 12/15/2024, 10:22 AM, at the nurse's station with V5 (Certified Nursing Assistant) and V6 (Certified Nursing Assistant), V5 states that the call light system is at the nurse's station. It will alert (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 2 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 12/16/2024 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)