Health inspection·October 25, 2024

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a proper blood draw from a resident with limb precautions. This failure affected 1 resident (R1) of 3 reviewed for laboratory services. Residents Affected - Few Findings include: On 10-22-24 at 9:55 AM, V8 (Concerned Party) said 3rd Party Company came to facility and drew blood from R1's wrong arm despite the right arm precaution bracelet and sign at head of the bed. V8 said POA was present and POA told V2 (Director of Nursing) and primary nurse. V8 said V2 and primary nurse said they were not aware of lab coming to draw labs on 10-10-24. V8 said R1's arm was swollen as a result of the incorrect blood draw. On 10-24-24 at 9:29 AM, V1 (Administrator) said V2 reported the incorrect blood draw to him. V1 said V1 and V2 went to R1's room and visualized limb R1's alert signage above the bed and R1's limb alert bracelet. On 10-23-24 at 10:23 AM, V2 (Director of Nursing) said R1 had a bracelet and sign above the bed indicating right arm precautions (no blood draws and blood pressures). V2 said all staff was aware because of bracelet, sign, physician orders, and possible CNA tasks (computer charting). V2 said lab tech came to draw labs from R1's right arm despite right arm precautions. V2 said R1's family said R1's arm was already swollen. V2 said she did not notice any additional swelling to R1's arm after the blood draw. V2 said it would be best practice for lab tech to get minimal report (precautions) from the nurse. V2 said she encourage staff to engage lab tech if they have any questions. Family made concern of improper lab draw. DON notified MD and received order for Doppler study to right arm. V2 called 3rd party lab and the 3rd party lab liaison came to facility to meet R1 and family. V2 said liaison verified R1's bracelet and limb alert sign above bed. On 10-22-24 at 10:20 AM, V3 (Licensed Practical Nurse) said she was aware of no blood draws or blood pressures to R1's right arm. V3 said this was charted in resident record, stated in communication report, wrist band stating right arm restriction, and sign found in the resident room. V3 said family was present and would be able to remind staff. V3 said she recalls R1's right arm swollen after the blood draw. V3 said she does not recall R1 complaining of pain. V3 said she is not aware of any further issue. On 10-22-24 at 10:57 AM, V4 (Licensed Practical Nurse) said she was aware of R1's right arm restriction because she admitted R1 with orders for right arm precautions, V4 saw R1's bracelet, and facility made sign indicating right limb precaution. V4 said she did not work when R1 blood was drawn. V4 said she is not aware of any adverse reaction after blood draw and did not notice any changes. V4 (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 2 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 10/25/2024 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)