Health inspection·April 8, 2025

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 Based on observation, interview, and record review, the facility failed to ensure residents who are dependent on staff for activities of daily living received oral care for 2 of 6 residents (R1, R2) reviewed for oral care in the sample of 6. Residents Affected - Few The findings include: 1. R1's Physician Orders for April 2025 shows and order dated 7/16/24, Oral care as needed and oral care every 8 hours. R1's Care Plan, dated 8/26/24, shows, (R1( has oral/dental health problems (cavities) related to poor oral hygiene and to provide mouth care as per Activities of Daily Living (ADL) personal hygiene. R1's Nurse Practitioner Progress Note, dated 4/7/25, shows, (R1's) cognitive function continues to improve, answers simple questions appropriately. On 4/8/25 at 10:37 AM, V4, Certified Nursing Assistant (CNA), had just performed incontinence care, and was washing R1's face. V4 gathered dirty linen and garbage and told R1, see you later. R1 was laying in bed on her back, with a clean gown and bedding. R1 had white/yellow debris in between her bottom teeth, and a film over her top and bottom teeth. R1 was able to respond to questions and when asked if her teeth had been brushed this morning she whispered, no. On 4/8/25 at 10:13 AM, V6 (R1's sister) stated, They are not brushing R1's teeth, and there is plaque on her teeth. A couple weeks ago, our dad visited and noticed her teeth were full of plaque and there was stuff in between her teeth. This past Sunday, I visited, and her teeth had a large amount of white/yellow stuff in between and she had very bad breath. I would expect that she, like a normal person, would have her teeth brushed twice a day. On 4/8/25 at 12:10 PM, V5, CNA, said oral care is done every day, including brushing the residents teeth. V5 said if the resident is not able to spit out toothpaste, she uses the mouth sponge with mouthwash on it to get the gunk out. On 4/8/25 at 12:14 PM, R1 was in bed and smiling. R1 still had visible white/yellow debris in her teeth. When asked if someone brushed her teeth this morning she whispered, no. 2. R2's Physician Orders shows an order, dated 6/19/24, oral care as needed and oral care every 8 hours. R2's Care Plan, dated 1/20/20, shows R2 has an a ADL self care performance deficit related to (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: 145669 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 04/08/2025 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)