Inspection·August 20, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a record of controlled substances proof of use accounting for each dose of narcotic medications given and disposed. This failure affected 15 of 15 residents (R6-R21) who were reviewed for disposition of controlled drugs. Findings include: This survey was conducted on-site in the facility from [DATE] to [DATE]. On [DATE] at 2:43pm V2 Director of Nursing and V3 Nursing Supervisor were interviewed regarding reconciliation and destruction of controlled medications. V3 and V4 said that they, along with V4 Assistant Director of Nursing were responsible for disposing controlled medications that were discontinued or not sent home with the residents. V3 said that they were unable to provide documentation in any of the resident's health record that accounted for each dose of controlled medication used and/or disposed. V3 said that once the medications were disposed under witness, the individual Resident Controlled Drug Receipt/Record/Disposition Form was disposed in the shredder and not uploaded into the electronic record. V3 was unable to provide explanation for this practice or how discrepancies were able to be reviewed without the sheet accounting for each dose. On [DATE] at 9:37AM V1 Administrator said that the facility did not have a policy stating that the forms needed to be preserved in the resident records. During this investigation, the facility provided two versions of forms used by nursing staff to record use of controlled substance medications: Controlled Substances Proof of Use and Controlled Drug Receipt/Record/Disposition Form. Both forms state which both state in part: Every dose must be accounted for. Facility policy titled Medication/Narcotic Destruction revised 11/17 states in part: 8. The drug disposition record must contain, as a minimum, the following: a. Resident's name, b. Date drug destroyed, c. Name of drug, d. Strength of drug, e. Prescription number, f. Quantity destroyed, g. Method of destruction, h. Signatures of witnesses. On [DATE] at approximately 3:00pm V2 Director of Nursing provided Drug Disposition Records from [DATE], [DATE] and [DATE]. These forms provided by V2 did not include the method of destruction as stated in the policy. V2 said that the forms were kept for their own records in the office and said the form was personally taken from the Internet. V2 said they were unaware that the disposal of medications should be reflected on the resident's individual record which is accompanied with the medication (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 3 Event ID: 145779 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 08/20/2024 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)