Health inspection·March 5, 2025

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Based on interview and record review, the facility signed/forged a residents family members name without permission to the admission contract without permission. This affected one of three residents (R1) reviewed medical records. Findings Include: On 2/25/25 at 10:28am, V17 (family) said, V1 forged her name on R1's admission package to take all of her assets. admission contract on the tablet to meet his deadline from corporate. V7 said, he realized it was wrong so he got rid of his signed package. V7 said, a copy was automatically emailed to V17. Police report dated 2/24/25 documents: V17 (R1's emergency contact #1) she is a representative for R1. V17 states she received an admission packet through email from the facility. V17 stated, the packet contained her signature that she did not authorized, nor sign on the paperwork. Page 1 of 7 145671 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm Based on interview and record review, the facility failed to transfer one resident to the hospital after a new onset of pain and abnormal x-ray results for an acute fracture. This affected one of three residents (R2) reviewed for radiology results, and nursing assessments. This failure resulted in R2 having increased pain and a 5 day delay in sending R2 to the local hospital for treatment. Residents Affected - Few Findings Include: R2 has diagnoses of Osteoarthritis, Syncope Episode, Radiculopathy, Raynaud's syndrome and a fall with Right hip fracture. Physiatry Progress noted dated 2/7/25 documents: Service date: 2/6/2025 documents: The patient (R2) was seen and examined today. Received R2 today up in the bed with complaints of pain to her right hip. Tenderness to touch. This is an old right hip surgery. R2 reporting new-onset pain. R2 has limited range of motion to that right leg with pain. R2 was amenable to an x-ray to the right hip. Assessment: Recent right hip fracture/fracture care. Right leg contracture. New-onset right hip pain. X-ray PA and lateral pending. Radiology results report dated 2/7/25 documents: Postersuperior dislocation of the right prosthetic femoral head with acute fracture of the posterior right acetabular (socket of the hip joint) wall. The femoral head prosthesis remains in good position with the femur. Pronounced osteopenia. Most probably is a pathological fracture due to advanced osteopenia. On 2/27/25 at 12:18pm, V3 (Nurse) said, she received the x-ray results. V3 said, she relayed the result to V20 (Medical Doctor) who did not give any new orders. V3 said, she did not assess R2 at that time. V3 said, she merely relayed the results to the doctor and nothing more. Physician order sheet dated 2/6/25 documents: Right hip, unilateral with pelvis when performed 203 views. Sent for imaging 2/6/25 5:05PM central time (CT). Radiology note dated 2/7/25 document: Right hip x-ray relayed to V20 (medical doctor). No new orders. On 2/27/25 at 12:45PM, V2 (Director of Nurses/DON) said, R2 was seen by V15 (Nurse Practitioner/NP) on 2/6/25. R2 did not have any new pain. R2 had a pervious fracture to that right hip. R2's pain was at baseline. V16 ordered an x-ray. V3 (Nurse) called V20 (Medical Doctor) with the results. V2 said, V20 did not given any new orders. V2 said, she was not aware of R2's x-ray results at that time. V2 said, she reviewed R2's x-ray results saw it documented an acute fracture. V2 said, she used her nursing judgement, called the doctor for an order to transfer R2 to the hospital. R2 denied incident. On 2/27/25 at 3:55PM, V2 said, she would have verified the x-ray results with V20 to ensure he heard what she read. V2 said, R2 should have been sent to the hospital when the x-ray was received. V2 said, she should have been notified. V2 said, she would have made the call to send R2 to the hospital if she had been notified. V2 said, she expected V3 to notify her of R2's fracture. V2 said, V3 is being placed on a performance action plan which includes a focused assessment. V2 said, V3's performance action plan was not complete or available for review during this survey. On 2/28/25 at 2:32PM, V20 (Medical Doctor) said, he instructed the nurse to get R2's previous x-ray for comparison. V20 said, it was late Friday when he got the call about R2's x-ray results. V20 said, it was over the weekend and the facility could not get R2's previous x-ray. V20 said, he was told 145671 Page 2 of 7 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0684 Level of Harm - Actual harm R2's fracture might be a new. V20 said, he instructed the facility to send R2 to the hospital. V20 said, V2 mentioned, something might have happened during therapy. It might have occurred with therapy when R2 was being transferred from the bed to the chair. If R2's fracture was new it should have fractured at the femur first. Residents Affected - Few Physician Progress note dated 2/11/25 documents: R2 was complaining of right hip pain. R2 was at baseline. R2 denies any falls. Per x-ray of R (right) hip/pelvis, showed advanced osteopenia right femoral head. Prosthesis was in good position; however, it did show posterior/superior dislocation of right prosthetic femoral head with acute comminuted fracture of Right acetabulum. Assessment: Right prosthesis dislocation. Progress note dated 2/11/25 documents: R2 transferred to the hospital for evaluation of right hip prosthesis dislocation and increasing pain. R2's physician order sheet dated 2/11/25 documents: Transfer resident to the hospital. Facility incident report dated 2/11/25 documents: Injury type: Fracture. R2 denied any incidents or falls that occurred in the facility. Runsheet dated 2/11/25 documents: Dispatched to nursing home, for R2 with a possible hip fracture. R2 was favoring her left hip due to pain. Assessment on R2 revealed nothing abnormal other than some pelvic pain. Primary Impression: Pain (acute) due to trauma. Hospital paperwork dated 2/11/25 documents: R2 present with right hip pain and deformity status post aggressive transferring in the bed at the nursing home two weeks ago. R2 has not ambulated in three weeks because nursing home restricted her from walking. R2 baseline is alert times two. Imaging yesterday shows posterior/superior dislocation of right prosthetic femoral head with acute comminuted fracture of Right acetabulum wall. R2 denied any recent fall or trauma to her right lower extremity. Review of systems: Positive right hip pain. Comments: Right hip tenderness to palpation. Musculoskeletal: right hip deformity. 145671 Page 3 of 7 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

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 interview and record review, the facility failed to provide a safe enviroment while providing direct incontinence care. This affected one of three residents (R8) reviewed for saftey while providing care. This resulted in R8 losing his balance and falling to the floor and sustaining a left hip fracture requiring surgical intervention. Findings Include: R8 has diagnoses of Alzheimer's Disease, Syncope And Collapse, Hypertension, Dementia without Behavioral Disturbance and Anxiety, Lack Of Coordination, Difficulty In Walking, Weakness and Cognitive Communication Deficit. Minimal data set section C (cognitive pattern) dated 1/16/25 documents a score of three which indicated severe cognitive impaired. Section GG (functional abilities) documents: R8 requires supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently with toileting hygiene and walk ten feet. Care plan initiated 11/30/22 documents: R8 is at high risk for falls related to decreased mobility, balance and endurance. Fall assessment dated [DATE] documents: R8 was at moderate risk for falling for overestimate or forget limits. On 2/28/25 at 1:37PM, V21 (Certified Nurses Assistant/CNA) said, V21 was providing incontinence care for R8 after a bowel movement. V21 said, R8 was standing up next to his bed. V21 said, she removed the tape/sides of R8's adult brief. R8 can walk a little. V21 said, she started cleaning R8's buttock, asked R8 if he had to urinate to which R8 replied, no. While standing up R8 started too urinated. V21 said, she jumped back, urine came out of nowhere. V21 said, some urine got on her pant leg. R8 had on socks, he attempted to ambulate, walk toward V21 to go to the bathroom but slipped in his urine. V21 said, she attempted to grab R8 but could not. V21 said, she did not lower R8 to the floor. V21 said, she could not reach R8 after she moved out of the way. V21 said, the space she was providing incontinence care was tight, very little room. Fall incident dated 2/14/25 documents: R8 was observed on his back near his bed. Mental status: oriented to person. Predisposing environmental factor: wet floor, Predisposing Physiological factors: confused, gait imbalance, impaired memory and incontinent. Predisposing situation factor: other-prostate cancer with frequent urination. R8's nursing note dated 2/14/25 documents: At 6:30am writer summoned by staff (V21) to the resident room. Resident observed on his back near his bed. When asked what happened. The resident was unable to state. V21 stated that resident was slipping on urine and I tried to prevent him from falling by easing the resident to the floor. Order of an x-ray of the right hip and leg received and carried out. On 3/4/25 at 11:27AM, V2 (Director of Nurses/DON) said, incontinence care should be done on the bed or in the bathroom. If R8 had to stand up to be cleaned, he should have been in the bathroom, holding onto to the rail for stability. V21's counseled regarding: standard of conduct: Performing work in an unsafe manner and poor work performance. Any time a resident is gotten out of bed staff are required to apply foot (non-skid 145671 Page 4 of 7 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0689 slippers, shoes). Required Corrective Action: Immediately improvement with adherence to safety is required when assisting resident out of bed. Level of Harm - Actual harm Residents Affected - Few On 3/5/25 at 12:29PM, V22 (Nurse) said, R8 was on his back on the floor when he entered R8's room. R8 did not have any abnormalities to the eye. R8 was not wearing any socks or shoes. R8's left hip was painful to touch. R8's room was very small. V22 said, there was nothing for R8 to hold on too when he was standing up. V22 said, R8 urinated and slipped in his urine. Subsequent visit dated 2/14/25 documents: Patient (R8) was seen today after he had slipped down while CNA attempted to assist patient back to bed. He had urinated on floor and slipped in the urine during transfer. He was laid onto the floor and Nursing completed head to toe exam. No injuries found. X-rays ordered of bilateral hip and knees. Fall on same level from slipping, tripping and stumbling without subsequent striking against object. X-ray dated 2/14/25 documents: Acute nondisplaced left femoral intertrochanteric fracture. Facility final reportable dated 2/20/25 documents: R8 experienced a witnessed fall. Per nurse on duty, while staff was administering patient care, R8 began to urinate on the floor, then attempted to ambulate to the restroom in his room losing his balance and began to fall. Staff attempted to stop resident from walking but was unsuccessful. R8 was eased to the floor. Staff observed R8's left lower extremity with irregular positioning. Affected limb immobilized. R8 complaint of pain to his left leg. Hospital paperwork dated 2/14/25 documents: R8 was brought in secondary to left hip pain after fall at the nursing home. CT lower left extremity dated 2/14/25 documents: Suspected Stress fracture. Acute comminuted intertrochanteric fracture of the left femur with impaction of the fracture segment requiring a left intramedullary nail (metal rod inserted into the thigh bone to treat fracture). Fall Preventive Program dated 11/28/12 documents: To assure safety of all residents in the facility, when possible. Use and implementation of professional standards of practice. 145671 Page 5 of 7 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview and record review, the facility failed to have pain medication available Hydrocodone-acetaminophen PRN (as necessary). This affected one of three residents (R6) reviewed for pain. This resulted in R6 being without pain medication and stated she was in extreme pain for about 1 day. R6 was status post laminectomy. Residents Affected - Few Findings Include: R6 has a diagnosis of Spinal stenosis, lumber region with neurogenic claudication, lumbago with left side sciatica and Osteoarthritis. Brief interview for mental status dated 1/21/25 documents a score of 15 which indicates cognitively intact. Nursing note dated 1/16/25 documents: resident (R6) was admitted post lumber laminectomy (surgery to ease pressure on the spinal cord and nerves of the lower spine). On 2/28/25 at 10:32AM, R6 who was assessed to be alert and oriented to person, place and time said, she was admitted after having back surgery. R6 said, she was in extreme pain for two or three days with no relief from the pain patch and muscle relaxer. R6 said, the nurse failed to refill her Hydrocodone-acetaminophen when there was only five pills left in the bingo card. R6 said, her pain was so bad she cried. On 2/28/25 at 3:32PM, V12 (Nurse) said, R6 was out of pain medication for one day. R6 complained of pain. R6 had muscle relaxants. R6 was p*ssed. V12 said, she offered R6 acetaminophen and muscle relaxant but R6 refused both medications. R6 wanted Hydrocodone-acetaminophen. Control Drug Receipt/Record/Disposition Form dispensed dated 2/2/25 documents: quality dispensed -thirty, (2/13/25) documents: amount given one, amount left zero. Nursing note dated 2/14/25 documents: R6 left facility going to appointment. R6 complained of pain writer offered resident, as needed acetaminophen, R6 refused medication times two nurses are present at bedside. Nursing note dated 2/14/25 documents: As need muscle relaxant was offered, resident refused. This writer contacted pharmacy for as needed medication order status, writer was transferred to the pharmacist for STAT order delivery, initial attempt was unsuccessful, writer is redirected and spoke with pharmacist, pharmacist directed writer to remove medication from nexus and contact pharmacy for code once medication is required. On 2/28/25 at 11:33AM, V23 (pharmacy) said, we needed a new prescription for R6's Hydrocodone-acetaminophen on 2/13/25. We received a prescription on 2/13/25. A thirty day supply of Hydrocodone-acetaminophen pills was sent to the facility on 2/14.25. On 3/4/25 at 12:36PM, V2 (Director of Nurses/DON) said, R6's Hydrocodone-acetaminophen pain medication was not removed from the nexus. V2 said, she does not have the Control Drug Receipt/Record form with the nurse's signatures on it dated 2/15/25 from R6's delivered medication. Physiatry progress note dated 2/14/25 documents: service date 2/13/25- Received patient (R6) today up on the side of the bed with complaints of pain to her back, requesting a Norco (Hydrocodone-acetaminophen). She continues to report that Norco provides acceptable pain relief. 145671 Page 6 of 7 145671 03/05/2025 Elevate Care South Holland 16300 Wausau Street South Holland, IL 60473

F 0697 Level of Harm - Actual harm Medication Administration record dated 2/1/25- 2/28/25 documents: Hydrocodone-acetaminophen oral tablet 5-325mg -give 1 tablet by mouth every four hours as needed for pain. Thursday 2/13/25 last dose of medication given was documented at 2:29pm. Pain scale dated 2/13/25 (11:23pm/11:24pm) documents a pain scale of five out of ten. No medication was documented given for 11:23/11:24 pain scale. Residents Affected - Few R6's pharmacy packing slip proof of delivery dated 2/15/25 documents: Drug name: hydrocodone-acetaminophen 5-325mg (milligrams), quality thirty pills delivery time at 6:33am. Control Drug Receipt/Record/Disposition Form dispensed dated 2/15/25 was requested from V2 (DON) and not provided/available during this survey. Pain Assessment Policy dated 11/28/12 documents: to establish guidelines for appropriate and intervention to manage pain. Medication will be administered at specific request of the patient and when the patient refused other such interventions. 145671 Page 7 of 7