Health inspection·October 18, 2024

F 0684 (RN). This order type was entered as Standard Diagnostic. (The order type should show STAT if order was requested to be completed immediately.). Level of Harm - Actual harm Residents Affected - Few R1's X-ray Report, dated 10/8/24, showed R1 had an acute intertrochanteric fracture of the proximal right femur with mild varus deformity (an excessive inward angulation of the distal segment of the bone). This X-ray was digitally signed by the Radiologist on 10/8/24 at 8:10 PM. This document showed the X-ray was reviewed by V4 (Assistant Director of Nursing - ADON) on 10/9/24 at 2:57 PM. R1 fell at 4:00 PM. The X-ray was read by the radiologist at 8:10 PM, but the facility did not review the results and transfer R1 to the hospital until the afternoon of 10/9/24, over 20 hours after the unwitnessed fall. R1's has no progress notes from 10/7/24 at 1:24 PM until 10/9/24 at 2:12 AM, that demonstrates continued monitoring of pain and the resident's condition. This note showed, The resident was sent to (local emergency room) via ambulance at 2:12 PM. (This note was entered by V6 (Licensed Practical Nurse LPN) and she worked 7 AM to 3 PM on 10/9/24; she wasn't in the building at the time of this note entry. R1's Change in Condition noted, dated 10/9/24 at 12:50 PM, showed R1 had decreased mobility, pain, and X-ray results showed she had an acute fracture. This note showed R1 a non-emergent ambulance was contacted with an ETA (estimated time of arrival) in 30 minutes. R1's Radiology Note, dated 10/9/24 at 12:50 PM, showed R1's X-ray results were received, relayed to the doctor, and orders were given to send R1 to the hospital for an acute intertrochanteric fracture of the proximal right femur with mild varus deformity. R1's Hospital Records showed she was admitted on [DATE] at 2:45 PM (22 hours after R1's unwitnessed fall that resulted in a right hip fracture).These records showed R1 was presented to the hospital after a fell yesterday evening at the facility. R1's X-ray showed an acute intertrochanteric fracture of the right femur. R1 had pain with movement of her right leg. R1 was admitted for orthopedic evaluation. R1 was a poor surgical candidate and returned to the facility on [DATE] with non-weight bearing (NWB) status to her right leg. On 10/16/24 at 12:51 PM, V6 (LPN) said she wasn't working when R1 fell (10/8/24 at 4 PM), but she was the nurse that sent R1 to the hospital on [DATE]. V6 said she sent R1 to the emergency room around mid-day 10/9/24 because her X-ray showed a fracture. V6 said R1 is alert to person/place and can tell you what she needs/wants. V6 said R1's voice is very quiet, but she can answer questions. V6 said R1 complained of right leg pain (10/9/24) and she notified V3 (DON) and V4 (ADON). V6 said the decision was made to send R1 to the hospital. On 10/16/24 at 1:54 PM, V3 (Director of Nursing/DON) said he was off when R1 fell (10/8/24), and when she was sent to the hospital (10/9/24). V3 said he got a phone call from V11 (Nursing Supervisor). V3 said V11 told him that he was doing rounds and found R1 on the floor. V3 said an hour later he got a call from V13 (R1's RN), and he said R1 was having pain, the doctor was called, and an order for an X-ray was obtained. V3 said it was about 5:30 PM. V3 said he would have expected the nurses to enter the X-ray orders as STAT. V3 said he would have to review the X-ray order to see how it was entered. V3 reviewed the report and said the Order Type was standard or routine, not STAT. V3 said the X-ray should have been ordered STAT to ensure the results were received in a timely manner and any injuries could be treated properly and timely. V3 said the X-ray results weren't received until close to noon on 10/9/24. V3 said the X-ray showed R1 had an acute right hip fracture, the provider was notified, and she was sent to the emergency room. V3 said after the X-ray was completed, then he expects the nurses will watch the chart for the results and relay the results to the provider as soon as possible. V3 said R1's X-ray showed she had a fracture and it's important to get her to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145669 If continuation sheet Page 2 of 6 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 145669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Waukegan 2222 Audrey Nixon Boulevard Waukegan, IL 60085 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 0684 hospital for an appropriate evaluation and treatment of the injury. V3 said it shouldn't have taken so long to get R1's X-ray results, but they have had issues with the company that completes their X-rays. Level of Harm - Actual harm Residents Affected - Few On 10/18/24 at 8:23 AM, V19 (RN) said she worked as the Nursing Supervisor on 10/8/24 from 11PM to 7 AM. V19 said she was told R1 fell on 3-11 shift and wasn't acting like herself. V19 said she remembered seeing R1 was weak and complaining of pain. V19 said she wasn't sure what time the X-ray was completed, but she did not receive the results. V19 said she did not review R1's chart for the X-ray results. V19 said on 10/9/24 when she gave report, she notified the on-coming supervisor to watch for the X-ray results. V19 said she checked with V20 (R1's nurse 10/8/24 11P-7A) and she said she didn't have results. V19 said there have been problems with the X-ray company and there sometimes are delays in the report times. On 10/18/24 at 8:59 AM, V17 (Certified Nursing Assistant/CNA) said she was R1's CNA from 11 PM to 7 AM on 10/8/24. V17 said she provided care to R1 2-3 times during her shift. V17 said R1 was grimacing, wincing, and moaning whenever she had to turn her to provide care. V17 said it seemed like R1 was having pain in her right hip. V17 said she reported it to V20 (R1's nurse) and she said that she knew about it. V17 said R1 stayed in the bed all night. On 10/18/24 at 9:05 AM, V20 (LPN) said she was the only nurse working R1's floor 11 PM to 7 AM on 10/8/24. V20 said R1 fell on 3-11 shift and stayed in bed all night. V20 said she did get report that R1 complained of pain in her right leg. V20 said she was told an X-ray was done and they were waiting on the results. V20 said she didn't get any calls from the X-ray company about R1's X-ray results. V20 said she notified the day shift nurse to follow-up on the X-ray results. On 10/18/24 at 9:59 AM, V22 (Nurse Practitioner/NP) said R1 was not one of her regular residents, but she was covering for another NP. V22 said she received an urgent call form the facility on 10/8/24 that R1 had fallen, her leg was swollen, and they were requesting X-ray orders. V22 said she gave orders for immediate X-rays and she didn't hear anything back from the facility until the next day. V22 said when a STAT order is given, she would expect the results to be received quickly. V22 said sometimes the X-ray company will call the results, but not always. V22 said it's been a problem, but the nurse should also be watching for the X-ray results in the computer. V22 said she would check her messages to determine the time she was notified. V22 said she received a message from V4 (Asssistant Director of Nursing/ADON) at 9:37 AM regarding R1's X-ray showing a fracture. V22 said R1's doctor was also notified, and he gave orders to send her to the hospital. V22 said she had no idea R1's X-ray results were available the night before. V22 said if she would have received the results then, R1 would have been sent to the hospital sooner. V22 stated, They didn't communicate with me. The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results Policy, revised 3/14/18, showed, Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care . Guidelines for Reporting Abnormal Results: .X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: pneumonia, new fracture . The licensed nurse is responsible for documenting the notification of results in the clinical record. The facility's Physician-Family Notification-Change in Condition Policy, reviewed 7/8/24, showed, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145669 If continuation sheet Page 3 of 6 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 145669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Waukegan 2222 Audrey Nixon Boulevard Waukegan, IL 60085 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for a resident at high risk for falling for 1 of 3 residents (R1) reviewed for falls in the sample of 4. This failure resulted in R1 experiencing an unwitnessed fall and sustaining a right hip fracture. The findings include: R1's Facesheet, dated 10/16/24, showed diagnoses to include, but not limited to: displaced interrogate right femur fracture; stage 2 CKD (chronic kidney disease); hemiplegia and hemiparesis following a stroke; dysphagia; dysarthria; severe-protein calorie malnutrition, vascular dementia, and anxiety. R1's facility assessment, dated 8/30/24, showed she had moderate cognitive impairment; and required partial to moderate assistance with eating, bed mobility, and transfers. R1's Fall Risk Assessment completed 7/3/24 showed R1 was at High Risk for Falling. R1's Care Plan, initiated 4/18/24, showed R1 was at high risk for falls related to confusion and gait/balance problems. On 10/16/24 at 1:22 PM, R1 was lying on her back, in bed. R1 said she did fall, but was unable to provide any further details of the fall. R1 said her right leg hurt when she had to move. R1's Risk Management, dated 10/8/24, showed, Nursing supervisor noted resident lying on the floor on the right side of her bed during rounds. Resident dressed with non-skid socks on. (R1's) wheelchair noted to be on the left side of the bed. (The) resident stated, I fell, I don't remember. This document showed R1 had facial grimacing and moaning when right leg moved after the fall. This form showed R1's pain was rated at a 5 on a scale from 1-10 (10 being the worst pain). The Facility's Fall investigation provided showed the following statements. V13 (Registered Nurse - RN) said he was passing medications when the nursing supervisor noted R1 lying on the floor on the right side of her bed. A head to toe assessment was completed with full ROM (Range of Motion) present. R1 complained of pain later on during the evening to her right leg. There was no swelling or bruising noted at this time. The NP (Nurse Practitioner) was notified and orders were received for X-rays of the right leg. Pain medications was administered. This form showed V15 (Certified Nursing Assistant - CNA's) statement was that she did not see R1 on the floor 10/8/24. This form showed V11 (Nursing Supervisor's) statement was he saw R1 on the floor, during rounds. V11 said R1 was lying on her right side, on the right side of her bed and her wheelchair was on the opposite side of the bed. R1's Care Plan, initiated 10/15/24 (after R1's fall), showed R1 required the use of a full body lift for transfer secondary to NWB (non-weight bearing) status to her right leg. R1's X-ray Report, dated 10/8/24, showed R1 had an acute intertrochanteric fracture of the proximal right femur with mild varus deformity (an excessive inward angulation of the distal segment of the bone). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145669 If continuation sheet Page 4 of 6 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 145669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Waukegan 2222 Audrey Nixon Boulevard Waukegan, IL 60085 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 - Actual harm Residents Affected - Few R1's has no progress notes from 10/7/24 at 1:24 PM until 10/9/24 at 2:12 AM, that demonstrates continued monitoring of pain and the resident's condition. This note showed, The resident was sent to (local emergency room) via ambulance at 2:12 PM. This note was entered by V6 (Licensed Practical Nurse - LPN and she worked 7 AM to 3 PM on 10/9/24; she wasn't in the building at the time of this note entry. R1's Change in Condition note, dated 10/9/24 at 12:50 PM, showed R1 had decreased mobility, pain, and X-ray results showed she had an acute fracture. This note showed R1 a non-emergent ambulance was contacted with an ETA (estimated time of arrival) in 30 minutes. R1's Radiology Note, dated 10/9/24 at 12:50 PM, showed R1's X-ray results were received, relayed to the doctor, and orders were given to send R1 to the hospital for an acute intertrochanteric fracture of the proximal right femur with mild varus deformity. R1's Hospital Records showed she was admitted on [DATE] at 2:45 PM (22 hours after R1's unwitnessed fall that resulted in a right hip fracture).These records showed R1 was presented to the hospital after a fell yesterday evening at the facility. R1's X-ray showed an acute intertrochanteric fracture of the right femur. R1 had pain with movement of her right leg. R1 was admitted for orthopedic evaluation. R1 was a poor surgical candidate and returned to the facility on [DATE] with non-weight bearing (NWB) status to her right leg. R1's October 2024 MAR (Medication Administration Record) showed she had pain at a level 5 on 10/8/24 at 9:52 PM and was administered Tylenol. This document showed R1 required Norco (opioid pain medication) after her fall. On 10/15/24 and 10/16/24 R1 was administered Norco for pain levels of 5 and 7. On 10/16/24 at 12:51 PM, V6 (Licensed Practical Nurse/LPN) said she wasn't working when R1 fell (10/8/24 at 4 PM), but she was the nurse that sent R1 to the hospital on [DATE]. V6 said she sent R1 to the emergency room around mid-day 10/9/24 because her X-ray showed a fracture. V6 said R1 is alert to person/place and can tell you what she needs/wants. V6 said R1's voice is very quite, but she can answer questions. V6 said R1 complained of right leg pain (10/9/24) and she notified V3 (DON) and V4 (ADON). V6 said the decision was made to send R1 to the hospital. V6 said R1 had been staying in bed since she returned from the hospital. On 10/16/24 at 1:07 PM, V7 (CNA) said he hadn't been assigned to R1 for a month or two, but R1 was able to ambulate with a walker and standby assistance. V7 said now R1 is in bed or the wheelchair. On 10/16/24 at 1:54 PM, V3 (Director of Nursing/DON) said he was off when R1 fell (10/8/24) and when she was sent to the hospital (10/9/24). V3 said he got a phone call from V11 (Nursing Supervisor). V3 said V11 told him that he was doing rounds and found R1 on the floor. V3 said an hour later he got a call from V13 (R1's RN), and he said R1 was having pain, the doctor was called, and an order for an X-ray was obtained. V3 said it was about 5:30 PM. V3 said he conducted interviews with the staff regarding R1's fall. V3 said prior to R1's fall she was walking with a walker. V3 said R1 had some weakness from a previous stroke, but she was able to ambulate with minimal assistance. V3 said since R1 returned from the hospital she required a total lift and was NWB to her right leg. On 10/16/24 at 2:55 PM, V11 (Nursing Supervisor) said he was doing rounds on 10/8/24 and found R1 on the floor, on the right side of her bed. V11 said it was approximately 4 PM. V11 said R1 was lying on her right side and her wheelchair was on the left side of the bed. V11 said R1 said she fell, but couldn't provide details of what happened. V11 said completed a head to toe assessment, reported the fall to V13 (R1's RN), and assisted him to use the total lift to transfer R1 back to bed. V11 said he didn't make any phone calls, but provided V13 (R1's nurse) with reminders to complete all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145669 If continuation sheet Page 5 of 6 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 145669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Waukegan 2222 Audrey Nixon Boulevard Waukegan, IL 60085 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 proper documentation and make phone calls to the provider and resident's family. Level of Harm - Actual harm On 10/18/24 at 8:23 AM, V19 (RN) said she worked as the Nursing Supervisor on 10/8/24 from 11PM to 7 AM. V19 said she was told R1 fell on 3-11 shift and wasn't acting like herself. V19 said she remembered seeing R1 was weak and complaining of pain. Residents Affected - Few On 10/18/24 at 8:59 AM, V17 (CNA) said she was R1's CNA from 11 PM to 7 AM on 10/8/24. V17 said she provided care to R1 2-3 times during her shift. V17 said R1 was grimacing, wincing, and moaning whenever she had to turn her to provide care. V17 said it seemed like R1 was having pain in her right hip. V17 said she reported it to V20 (R1's nurse) and she said that she knew about it. V17 said R1 stayed in the bed all night. On 10/18/24 at 9:59 AM, V22 (NP) said R1 was not one of her regular residents, but she was covering for another NP. V22 said she received an urgent call form the facility on 10/8/24 that R1 had fallen, her leg was swollen, and they were requesting X-ray orders. V22 said she gave orders for immediate X-rays and she didn't hear anything back from the facility until the next day. V22 said R1's right hip fracture was caused by the unwitnessed fall. The facility's Fall Prevention Program, revised 11/21/17, showed, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145669 If continuation sheet Page 6 of 6