Health inspection·June 23, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report abuse allegations to the State Agency for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. The findings include: R2's admission Record, dated 6/17/25, shows R2 is a [AGE] year-old male admitted to the facility on [DATE], with an admitting diagnosis of Amyotrophic Lateral Sclerosis (ALS). R2's current care plan, initiated on 3/31/25, shows R2 is very welcoming, alert, and oriented to person, place, time, and situation. On 6/17/25 at 9:50 AM, R2 said the Certified Nursing Assistant (CNA), V10, tried to break his oxygen concentrator by hitting it, and when she could not break it, she turned it off. R2 said V10 disabled his call light by pulling it out of the wall. R2 said the incident happened prior to 5/20/25, and he thinks it was during the night shift. R2 said he told a male nurse about it, and the nurse was going around getting statements, and they conducted an investigation. On 6/17/25 at 12:45 PM, V1, Administrator, said she did not report R2's allegations to the Illinois Department of Public Health (IDPH) because it was not reportable. V1 said V5, PM Nursing Supervisor, called her around 10:30 PM on 5/28/25 to report R2 told V5 that R2's Certified Nursing Assistant (CNA), V10, unplugged R2's oxygen concentrator and his call light to stop communications with others. V1 said, It's not like a major abuse case; there was nothing to report to IDPH. On 6/17/25 at 12:35 PM, V10 said she got suspended because R2 made allegations against her. V10 said R2 told the nurse she took the call light away from him and out of the wall so he couldn't use it, and called him a devil. On 6/17/25 at 1:11 PM, V2, Director of Nursing (DON), said he received a call from V5 on 5/28/25 between 9:00 PM and 10:00 PM. V5 reported R2 said V10 turned off his oxygen concentrator. V2 agreed if a staff member purposefully turned off a resident's oxygen concentrator, it would be considered abuse. V2 said V10 was asked to leave her shift on 5/28/25, and was suspended during the investigation. On 6/17/25 at 1:39 PM, V4, Licensed Practical Nurse (LPN), said she was R2's nurse when V10 came to her and told her R2 told V10 that V10 called him a devil. V4 said she went to R2's room and R2 told her V10 turned off his oxygen concentrator and called him the devil. V4 said she reported R2's concerns to the supervisor, V5. V4 said she and V5 called V1 and V2 to report the allegations. V4 said (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 06/23/2025 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)