Inspection·March 9, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few On [DATE] at 1:55 PM, interviewed R81 in her room. When asked if she had ever experienced poor staff treatment and/or abuse prior to today, R81 said I just wanted to get it done. Then added, I was scared of that one that was in here, there's one that always yells but so long as they help me, I'm not going to say anything. At 2:03 PM, R81 who appeared frustrated added if they want to yell, then I just let them go ahead and yell. On [DATE] at 2:15 PM, V1 (Administrator) said that she knows V8 (CNA) from a previous facility and V8 personally took care of her loved ones. V1 added that she knows V8 talks loudly because she is hard of hearing but has never know of V8 (CNA) to speak in this alleged manner. Reviewed V8's personal file which showed a physician assessment dated [DATE] that documented, patient denies any hearing loss. Reviewed V8's (CNA) training logs that showed she last completed abuse and neglect training on [DATE]. On [DATE], reviewed R81's MDS Section C - Cognitive Patterns dated [DATE] that showed her Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. Also reviewed R81's current plan of care which did not show an implemented care plan to prevent R81 from being abused. On [DATE] at 11:21 AM, when talking with R81 regarding the incident with V8 (CNA) from previous day, R81 said they come in and don't tell us who they are. They make me want to not care anymore. On [DATE] at 11:31 AM, V12 (Licensed Practical Nurse) said she started working at facility one month ago and completed abuse training during her orientation. When asked to name specific types of abuse, V12 said verbal, financial, and physical are the only ones I know of. On [DATE] at 01:39 PM, V19 (Certified Nursing Assistant) said she had just completed abuse training a week ago. When asked to name specific types of abuse, V19 said verbal, physical and that's all I know of. On [DATE] at 01:49 PM, V20 (Certified Nursing Assistant) who was assigned to the 400 unit said, her last abuse in-service was last night and types of abuse are verbal, sexual, physical, and abuse done to others. Reviewed Facility Reported Incident Final Abuse Reports for the last year until present and noted the following: On [DATE], a male (deceased ) resident complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing the resident. The allegation of physical abuse was not substantiated by V1 (Administrator). Reviewed resident's MDS Section C - Cognitive Patterns while at facility dated [DATE] that showed his Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. On [DATE], a surveyor reported an allegation of verbal abuse made by R75's spouse. Report indicates the residents involved were not interviewed due to cognition and the staff member involved denied verbally abusing any resident during her interview. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE], when interviewed by a surveyor about an incident that occurred on [DATE], R37 said she was verbally and physically abused by V28 (Certified Nursing Assistant). R37 then stated that she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 2 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0600 Level of Harm - Actual harm informed V28 was no longer employed at the facility. Report indicated the facility attempted to contact V28 for an interview but was unable to reach her. The allegation of verbal and physical abuse was not substantiated by V1 (Administrator). R37's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 14 out of 15 which indicated no cognitive impairment. Residents Affected - Few On [DATE], R37 complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing R37. The allegation of physical abuse was not substantiated by V1 (Administrator). On [DATE], R29 (hospitalized since [DATE]) complained of being verbally abused by a certified nursing assistant. R29's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 15 out of 15 which indicated no cognitive impairment. Report indicated the staff member was interviewed and denied verbally abusing R29. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE] at 09:50 AM, V1 (Administrator) was interviewed by the survey team regarding the outcome of her abuse investigations reviewed during survey. When asked how V1 concluded the allegations were all unsubstantiated, including those allegations made by residents who were cognitively intact, V1 (Administrator) said it's their word versus the staff because that's how I was trained. On [DATE], V1 provided final investigation report for R81 that did not indicate the result of investigation findings, whether abuse was substantiated or not. Report indicated surveyor reported to V9 (LPN) that V8 (CNA) was speaking loudly to R81 and indicated that V8 did not mean to sound frustrated she was trying to get her wheelchair untangled. Report also indicated V8 (CNA) was not frustrated with the resident but only with the cords restricting the wheelchairs mobility and that V8 did not intend to show any willful frustration towards R81. Report concluded with, the facility will do one on one abuse and customer service training with V8 prior to her return to work, will closely monitor V8 upon return by conducting random checks on residents she cares for. On [DATE] at 1:35 PM, requested R81's initial and most recent abuse/neglect screen and abuse care plan from V7 (Social Services Director) who said screenings should be completed upon admission, quarterly and with any allegations. At 2:39 PM V7 said the facility began screening residents for abuse or neglect and implementing abuse care plans as of [DATE]. At 2:44 PM, V7 (Social Services Director) said R81 was not screened for, or care planned for abuse upon her admission on [DATE]. V7 then provided R81's abuse/neglect screen dated [DATE] and abuse care plan with revision date or [DATE]. On [DATE] at 1:48 PM, when asked if there is required training to be the abuse coordinator, V1 (Administrator) said no, but I do yearly abuse training courses on-line. When asked when she last completed abuse training, V1 said I'll have to get back to you with the date. At 2:00 PM, V1 indicated her last abuse prevention and reporting training was completed on [DATE]. Reviewed Abuse Policy last revised [DATE] that showed the facility prohibits abuse and neglect by staff done by orientating and training employees on how to deal with stress and difficult situations. Policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means and provides examples of mental and verbal abuse include but not limited to yelling or hovering over a resident, with the intent to intimidate. Policy indicated under establishing a resident sensitive environment will be accomplished through: Resident Assessment: as part of the resident's life history on the admission statement, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 3 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Event ID: Facility ID: 145779 If continuation sheet Page 4 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent an accidental hazard for 1 (R69) out of resident reviewed for accident hazards in the sample of 37. Findings include: R69 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting unspecified side; Cerebral Infarction; Unspecified Dementia; Osteomyelitis; Tybe 2 Diabetes Mellitus; and Peripheral Vascular Disease. On 03/06/23 at 11:07 AM Surveyor observed straight needle with initiated safety cover, laying on the R69's comforter. Surveyor asked R69 if he was aware that the needle was there, R69 stated, No, I didn't know the needle was laying here, it was probably left this morning when they draw my blood. I'm not sure what time she was here. On 03/06/2023 at 11:11 AM Surveyor interviewed V12 (Licensed Practical Nurse), V12 stated, Nurses don't collect blood here at the facility, there is a contracted phlebotomy lab that sends their staff to collect blood. Leaving unattended straight needle on residents' linens has a potential to harm resident, staff, or visitor for variety of reasons. The biggest one, is the risk of contamination. Additionally, safety is a concern. Resident, staff, or visitors could get stuck by the needle. V12 (LPN) proceeded to remove straight needle form R69'scomforter and placed it in the sharps container available in R69's room. On 03/06/23 at 11:14 AM Surveyor interviewed V5 (Unit Manager), V5 stated, Phlebotomist is the one who must have left the straight needle on R69's comforter. We use contracted phlebotomy lab to collect our residents' blood samples. Phlebotomist was here this morning, between 8.30a-9.00a. Leaving straight needle on R69's comforter, poses risk of contamination to the resident, staff, and visitors. That's the biggest concern. Phlebotomy General Guidelines Policies and Procedures dated 9/15/2022 reads in part, When removing the needle; Immediately discard needle and tube holder in sharps container as one unit; Do not leave/place needle on patients bed side; Always discard used needles in sharps container immediately after blood draw; Always double check that al waste and equipment is not left behind (tourniquet, needles, etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 5 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow their policy on hand washing during food preparation and failed to properly wear hair nets during food preparation in the kitchen. This failure has the potential to affect all 97 residents who receive oral meals from the facility's kitchen. On 03/06/23 at 10:30 AM, during the kitchen observation, V17 [NAME] noted with a large amount of hair outside the back of her hair net while preparing food over the stove. V17 was inquired of her hair net. V17 [NAME] stated, Oh I thought it was all in. V17 [NAME] attempted to fix her hairnet by pushing the hair up into the net while standing at the stove and was instructed by V15 Dietary Manager to go over to the hand washing sink area away from the food. On 03/07/23 at 10:47 AM, V17 [NAME] observed touching the garbage can lid during preparation of pureed food. V17 [NAME] then rinsed her hands in the food preparation sink. V16 District Manager instructed V17 [NAME] to go to the hand washing sink. V17 [NAME] then rinsed her hands for less than 15 seconds and returned to preparing pureed food. V17 [NAME] was inquired of when to perform hand hygiene. V17 [NAME] stated, Sometimes I forget, it should be in the other sink. I should wash my hands for 15 seconds. V16 District Manager Yona Solutions stated, V17 only rinsed her hands off, she didn't wash her hands in it (food preparation sink). Dietary staff did not clean and sanitize the food preparation sink after V17 [NAME] rinsed her hands in it after touching the garbage can lid during puree food preparation. V17 [NAME] had previous in-service training for hand washing and infection control from 12/14/22, in-service training for infection control and hand washing from 1/18/2023. The Food & Nutrition Services Staff Attire Policy dated 9/1/21 states in part: Standard: All employees wear approved attire for the performance of their duties. Guidelines: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The Food & Nutrition Services Hand Washing Policy dated 9/1/21 states in part: Standard: Only wash your hands in sinks designated for handwashing. Do not wash your hands in utensil, food preparation or service sinks. 3. The entire process must last at least 20 seconds. 4. When to wash your hands, wash your hands as often as possible. It is important to wash your hands: -After handling soiled utensils and equipment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 6 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0812 -As often as needed during food preparation and when changing tasks. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 7 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review facility failed to follow isolation procedures and usage of PPE's (Personal Protective Equipment) for Enhanced Barrier Precautions for 5 (R12, R30, R37, R43, R58) residents; failed to post signage alerting visitors of active Covid case in the facility. This failure has a potential to affect all 98 residents currently residing in the facility. Residents Affected - Many Findings include: On 03/06/2023 at 09:35 AM Surveyor noted there are no signs in the entrance nor reception area informing of an active Covid case in the facility. On 03/06/2023 at 10:00 AM V1 (Administrator) confirmed that there is one active Covid case in the facility of a total census of 98 residents. On 03/07/23 at 10:35 AM Surveyor observed V13 (Certified Nursing Assistant) and V14 (Certified Nursing Assistant) perform incontinence care for R37. Surveyor observed Enhanced Barrier Precautions sign on R37's room door. Surveyor observed that V13 (CNA) and V14 (CNA) did not wear appropriate PPE, both V13 (CNA) and V14 (CNA) did not wear gown nor goggles or protective shield while performing R37's direct patient care. On 03/07/23 at 11:00 AM Surveyor interviewed V13 (CNA), V13 unable to explain what Enhanced Barrier Precautions are, when they are applied, and what kind of Personal Protective Equipment is required to wear under Enhanced Barrier Precautions; however, V13 confirmed that she and V14 provided direct patient care to R12, R30, R37, R43, R58. On 03/07/23 at 11:45 AM Surveyor interviewed V2 (Director of Nursing), V2 stated, Enhanced Barrier Precautions are somewhat new, they have been around for about a year, but staff was trained on how to apply them and what kind of Personal Protective Equipment is required to wear under Enhanced Barrier Precautions about eight months ago. 03/08/23 09:13 AM Surveyor interviewed V14 (CNA), V14 stated, Enhanced Barrier Precautions are a way to protect yourself and residents from pathogens. Staff should wear gown, gloves, mask, face shield or goggles, and wash their hands often. Surveyor asked why was V14 (CNA) wearing only mask and gloves while performing direct patient care on 03/07/23 to R12, R30, R37, R43, R58, V14 (CNA) stated, I don't know what happened yesterday. On 03/08/23 at 10:42 AM Surveyor interviewed V2 (DON), V2 stated, When we are in outbreak there is a sign in the reception area notifying residents of an outbreak. I don't know if one positive Covid-19 case would require a sign for visitors, I would have to check the policy. Surveyor and V2 verified/observed that there no signs in the entrance nor reception area informing of an active Covid case in the facility at this time. Infection Control - Interim Covid-19 policy dated 3/5/2020, revised 10/31/2022 reads in part, Communication to Residents, Representatives and Families. Inform residents, their representatives, and families of those residing in the facilities by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of Covid-19. Personal Protective Equipment Preventative Approach Guideline dated 07/13/2022 reads in part, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 8 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothes. MDROs may be indirectly transferred from the resident-to-resident during these high-contact care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Providing hygiene; Changing briefs or assisting with toileting. Event ID: Facility ID: 145779 If continuation sheet Page 9 of 10 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 145779 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review facility failed to inform residents, their representative, and families of confirmed Covid-19 case in the facility. This failure has a potential to affect all 98 residents currently residing in the facility. Residents Affected - Many Findings include: On 3/6/23 at 10:00 AM, V1 (administrator) provided the facility matrix census data showing 98 current residents in the facility. On 03/08/23 at 10:42 AM Surveyor interviewed V2 (Director of Nursing), V2 stated, When there is an outbreak in the facility, we notify residents, their representative, and families of an outbreak by mailers and phone calls. We didn't notify residents, their representative, and families of the one active Covid-19 case that we have right now at the facility. I don't know if one positive Covid-19 case would be considered an outbreak, I would have to check the policy. Infection Control - Interim Covid-19 policy dated 3/5/2020, revised 10/31/2022 reads in part, Communication to Residents, Representatives and Families. Inform residents, their representatives, and families of those residing in the facilities by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of Covid-19. This information must include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of each time a confirmed infection of Covid-19 is identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145779 If continuation sheet Page 10 of 10