F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
On 1/21/2025 at 11:30am R 34 was observed in bed asking for her call light, R34 call light was observed on
the floor under her bed out of reach.
Residents Affected - Few
On 1/21/2025 at 11:35am V11(Nurse) said her call light should be in reach and attached the call light to the
bed in reach.
On 1/23/2025 at 12:40pm V2(Director of Nursing-DON) said R34 has multiple sclerosis and she expect her
call light to be always in reach.
An admission record dated 1/23/2025 indicated that R34 has a diagnosis of multiple sclerosis. A care plan
dated 1/13/2023 indicates that R34 has a focus of at risk for falls related to deconditioning an intervention
to keep call light and desired personal items within reach.
Based on observation, interview, and record review the facility failed to ensure call light is within reach
affecting 2 of 2 (R2, R34) residents reviewed for Accommodation of Needs in a sample of 20
Findings Include:
On 1/21/2025 at 11:20 AM, R2 in bed, call light not within reached. V6 (Certified Nursing Assistant/CNA)
said R2 uses a custom call light that V6 was not able to find within R2's reach.
On 1/23/2025 at 10:45 AM, V2 (Director of Nursing/DON) said call light should be within reach of resident.
admission Record: Diagnosis Information
Cerebral Palsy, Unspecified
Contracture, Unspecified Joint
Care Plan:
Encourage R2 to use custom call light r/t contractures of all extremities for staff assistance.
Policy and Procedure:
Call Light, Revisions: 2-2-18
(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 4
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
01/24/2025
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 0558
Purpose: To respond to residents' requests and needs in a timely and courteous manner.
Level of Harm - Minimal harm
or potential for actual harm
Guidelines:
Resident call lights will be answered in timely manner.
Residents Affected - Few
1. All residents that have the ability to use a call light shall have the nurse call light system available at all
times and within easy accessibility to the resident at the bedside or other reasonable accessible location.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145779
If continuation sheet
Page 2 of 4
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
01/24/2025
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
On 1/21/2025 at 11:35 AM R6's CPAP machine on the nightstand with mask/cannula not stored in a
plastic/zip lock bag. V5 (Licensed Practical Nurse) said CPAP mask/cannula should be in the bag when not
in use.
Residents Affected - Few
On 1/23/2025 at 10:45 AM V2 (Director of Nursing) said CPAP mask/cannula should be stored in a
plastic/zip lock bag when not in use.
admission Record:
Diagnosis Information: Sleep Apnea, Unspecified; Obstructive Sleep Apnea (Adult) (Pediatric)
Order Summary Report:
CPAP to be worn at bedtime
Care Plan:
Interventions: CPAP to be worn at bedtime
Policy and Procedure:
Oxygen & Respiratory Equipment - Changing/Cleaning
Review/Revisions: 1-7-19
Guidelines:
Purpose:
1. To provide guidelines to employees for changing all disposable respiratory supplies.
2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies.
3. To minimize the risk of infection transmission.
Procedure:
2. Nasal Cannula
c. A clean plastic bag with a zip lock or draw string, etc. will be provided to store the cannula
when it is not in use.
Based on observation, interview, and record review the facility failed to ensure appropriate infection control
practices in proper handling of respiratory equipment. This deficiency affects two (R6, R23) of four residents
in the sample of 20 reviewed for Infection control.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145779
If continuation sheet
Page 3 of 4
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
01/24/2025
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
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
On 1/21/25 at 11:05 AM, R23 observed in wheelchair alert and responsive. R23 nebulizer mask observed
on top of dresser uncovered and tubing with no date or label.
Residents Affected - Few
On 1/21/25 at 11:10 AM, V5(Licensed Practical Nurse) made aware of above findings and said that
nebulizer mask should be covered in a plastic bag with date on tubing, V5 said nebulizer mask should not
be left on top of dresser uncovered.
On 1/22/25 at 2:00 PM, V2 (Director of Nursing) said that her nebulizer masks should be placed inside a
plastic bag with tubing labeled and dated for infection control purposes.
Facility's Policy on Nebulizer- Medication Administration revision: 10-9-18
Guidelines
23. When equipment is completely dry, store in a plastic bag with the resident's name and date on it.
24. Change equipment and tubing weekly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145779
If continuation sheet
Page 4 of 4
