Inspection·December 4, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sacral pressure ulcer.R4's (10/16/25) risk assessment for developing skin integrity impairment determined a score of 11 (high risk). R4's (11/28/25) physician wound assessment includes Sacral (Stage 4) pressure ulcer measuring 5.1 x 3.4 x 0.6cm (centimeters). Exudate: serous, light. Treatment recommended on 11/28/25 - for 30 days: clean with NS (Normal Saline). Apply Calcium Alginate and Metrogel. Secure with dry dressing 3 times weekly and PRN.R4's POS includes (8/26/25) LALM in use check for proper functioning and settings every shift. (11/14/25) Hydrogel Gel (wound dressing) apply to sacrum every Monday, Wednesday, Friday after cleansing with NS - which is incongruent with R4's (1/28/25) physician recommended treatment orders. R4's (November 2025) TAR affirms administered sacrum treatments (on or after 11/28/25) exclude Calcium Alginate therefore (11/28/25) recommended physician orders were not transcribed and/or followed.R4's (6/23/23) care plan includes sacrum pressure injury, interventions: LALM in place with appropriate settings and functioning properly. During care place mattress setting on static for safety and return to appropriate settings once care is completed. On 12/2/25 at 2:22pm, surveyor inquired about R4's current sacrum treatment V5 (Wound Care Nurse) reviewed R4's EMR and stated, Hydrogel and dry dressing every other day, it was changed yesterday [prescribed Calcium Alginate - which absorbs exudate, was excluded]. Surveyor subsequently entered R4's room. R4 was lying atop of a LALM however the static button was affirmed to be broken - the light remained off when V4 (Wound Care Nurse) pressed the button on and off. Surveyor inquired if R4's LALM cells appeared to be alternating. V5 (Wound Care Nurse) responded, No, I don't see anything. Surveyor inquired about the comfort level of R4's LALM R4 replied It feels firm therefore likely in static mode. R4's sacrum dressing appeared wet - on the outside. R4's external dressing was removed; moderate serous exudate was noted on the dressing applied directly to the wound (which immediately fell off). A large sacrum wound was also noted however R4's medical records affirm the wound has significantly decreased in size. R2's diagnoses include (stage 4) pressure ulcer sacral region.R2's (11/18/25) risk assessment for developing skin integrity impairment determined a score of 13 (moderate risk). R2's (11/28/25) physician wound assessment includes sacral stage 4. Size: 0 x 0 x 0cm (centimeters) - therefore healed. Treatment recommended on 11/28/25: clean with NS, cover with foam island dressing for 30 days. Continue offloading. Date treatment initiated 11/21/25 (1 week prior). R2's POS includes (8/26/25) LALM. (9/12/25) Wound Care (Sacrum) cleanse with NS (Normal Saline), pat dry, apply collagen, cover with dry dressing 3 times weekly and PRN (as needed) - which is incongruent with R2's (11/28/25) physician recommended treatment orders initiated 11/21/25.R2's (November 2025) TAR affirms the (11/21/25) recommended sacrum treatment order clean with normal saline and cover with foam island dressing was excluded therefore physician orders were not transcribed and/or followed on or after 11/21/25. On 12/2/25 at 1:19pm, surveyor inquired about R2's treatment orders. V5 (Wound Care Nurse) reviewed R2's EMR and stated, Cleanse with normal saline, pat dry, apply collagen and dry dressing however Collagen was discontinued on 11/21/25 - per 11/28/25 physician wound assessment.On 12/2/25 at 1:21pm, R2 was lying in bed atop of a LALM with multiple layers of linen between the resident and mattress (impeding air flow). R2 was also wearing a disposable brief - adding an additional layer. Surveyor inquired about the linens atop of R2's mattress. V5 (Wound Care Nurse) stated, There's a draw sheet (referring to folded bath blanket) and the flat sheet. Surveyor inquired how many layers of draw sheet were beneath R2. V5 responded, 4 (therefore a total of 5 linen layers + the brief). V5 removed R2's sacrum dressing and a scar was present; the wound was healed. V5 subsequently cleansed R2's sacrum with NS, then applied collagen and bordered gauze dressing. Surveyor inquired why collagen was applied to a healed wound instead of hydrocolloid (a protective covering). V4 (Wound Care Nurse) replied, I (V4) believe the doctor closed it (wound) and wanted us (staff) to keep it (Collagen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145671 If continuation sheet Page 2 of 3 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 12/04/2025 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treatment) for a week however R2's (11/28/25) physician wound assessment affirms Collagen was discontinued - 11 days prior. On 12/2/25 at approximately 3:45pm, R2's EMR (Electronic Medical Record) was reviewed the POS affirms at 3:30pm (after surveyor observation/interview) sacrum wound care orders for Collagen and dry dressing were re-entered.Considering reasonable person concept and R2's healed wound; the foam island dressing (prescribed 11/21/25) or a hydrocolloid dressing are likely more appropriate than Collagen (which promotes healing). The pressure injury policy (revised (1/17/25) states physician ordered treatments shall be initialed by the staff on the electronic treatment administration record after each administration. [R2, R3, and R4's 11/28/25 physician ordered treatments were excluded from the November 2025 TARS].The (undated) facility LALM manufacturer guidelines state press ON to set the air overlay to static mode of OFF to set alternating pressure mode. Patients can directly lie on the overlay or cover with a sheet and tuck loosely to increase the comfort of the patient. Determined the patient's weight and set the control know to that weight setting on the control unit. NOTE! In static mode, the overlay provides a firm surface. Make sure the control unit is in good condition by checking if the indicators illuminate when the power is first turned on. Event ID: Facility ID: 145671 If continuation sheet Page 3 of 3