Inspection·December 13, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to follow their policy in ensuring that a urinary catheter drainage bag was placed in a privacy bag for one (R106) of three residents reviewed for dignity in a sample of 24. Findings include: R106's diagnosis include but not limited to benign prostatic hyperplasia without lower urinary tract symptoms, chronic heart failure, and retention of urine. On 12/10/24 11:44 AM - R106 was observed with V16 (LPN/Licensed Practical Nurse). R106 has a roommate who was lying on bed 1. R106 was lying on bed 2 by the window. R106's urinary catheter drainage bag was not placed in a privacy bag and was in view to anyone that enters the room. On 12/10/2924 at 11:45 AM, V16 said that the CNA (Certified Nurses Assistant) must have placed the drainage bag in view instead of moving it to the window side where it could have been out of view. V16 said that the drainage bag should have been placed in a privacy bag or placed by the window. On 12/11/2024 at 1:30 PM, V2 (Director of Nursing) said that the urinary catheter drainage bag should be in placed a privacy bag. Facility Policy: Urinary Catheter Revised Date: 2 - 14 - 19 Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines 7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly. May place drainage bag and excess tubing in a secondary vinyl bag or other similar device to prevent primary contact with floor or other surfaces. 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 5 Event ID: 145671 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 145671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473 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)