Health inspection·July 15, 2025

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to establish and maintain a system for recording and releasing resident funds based on generally accepted accounting principles. This applies to 1 of 3 residents (R1) reviewed for the resident fund in a sample of 8.R1 was an [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].On 7/10/25 at 9:10 AM, V10 (R1's granddaughter) stated, After my grandpa (R1) passed away on 6/7/25, my mom received a phone call from the nurse that R1 had $200 cash and a cashier's check of $400 to be picked up. When my mom and my grandma (who passed away one week after my grandpa) stopped by to collect money, V1 (administrator) told them that the money had already been released. But we never received that money. They are saying my grandma (who passed away) picked it up in April (4/7/25). But my grandma doesn't even drive. Somebody must have driven her to the facility, and we would know if that happened.On 7/10/25 at 12:15 PM, V2 (Director of Nursing/DON) stated, A Couple of months ago, the administrator gave money to the wife and daughter. He might have forgotten to record it. On 7/10/25 at 1:12 PM, V1 (Administrator) stated, R1's wife showed up at the nurses' station on 4/17/25 (before R1's death) to collect the money which was in an envelope in V2's office. I texted V2 asking for money. The money was in V2's safe, and since V2 wasn't available that day, I instructed V13 (Staffing Coordinator) to retrieve it from V2's office. The money was in an envelope, which V13 was to hand over to R1's wife. Our normal process of releasing resident funds is to have the responsible party sign the receipt for the money. Somehow, I don't have any proof available that the fund was released to the family.A review of the grievance form documented that the facility filed a grievance form on 6/10/25 in regards to R1's granddaughter's inquiry about R1's fund ($240 in cash and check). A review of the clinical records and documentations for April 2025 indicates that no documentation stating that the fund was released to R1's family. Page 1 of 4 145779 145779 07/15/2025 Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide residents with a clean, comfortable, home-like interior. This applies to 5 of 8 residents (R4, R5, R6, R7, and R8) reviewed for the sanitary, comfortable, home-like environment.On 7/10/25 at 10:20 AM, observed 300 hallways with urine and feces smell, and a common shower room with a dirty/foul smell.On 7/10/25 at 10:22 AM, V12 (Housekeeping) stated that he doesn't know where the foul smell is coming from, and he is on his way to clean the common shower room. 1.R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. On 7/10/25 at 10:30 AM, V3 (Certified Nursing Assistant/CNA) checked on R4 for incontinence and was found with urine and feces-soaked brief with urine and feces leaked onto pads and then to linen with brownish discolored linen. 2.R5 is a [AGE] year-old female having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 10:28 AM, observed R5 in her bed with an intense urine and feces smell. On 7/10/25 at 11:00 AM, V3 checked on R5 for incontinence and was found with feces-soaked incontinent brief with feces leaked onto incontinent pad and linen with brownish discolored linen. 3.R6 is an [AGE] year-old female with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene.On 7/10/25 at 11:10 AM, observed the hallway close to R6's room with an intense urine and feces smell. On 7/10/25 at 11:10 AM, V3 checked on R6 in the presence of V2 (Director of Nursing), V4 (Nurse/LPN), and V13 (staffing coordinator). R6 was observed with smelly urine and feces-soaked dark brownish incontinent briefs that leaked on the incontinent padding and then onto linen. 4&5R7 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the MDS dated [DATE].On 7/10/25 at 10:25 AM, R7 was in the hallway (just outside her room) and stated, Sometimes the hallways are smelly, my room is smelly because they just changed my roommate (R8)The facility presented an undated Housekeeping Services Policy document: it is the policy of the facility to maintain a clean, odor-free, comfortable, and orderly environment in all health care and public areas, which meets the sanitation needs of the facility and residents' right to a safe, clean, comfortable homelike environment. 145779 Page 2 of 4 145779 07/15/2025 Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 3 residents (R4, R5, and R6) reviewed for activities of daily living (ADL) care in a sample of 7. 1.R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. On 7/10/25 at 10:30 AM, V3 (Certified Nursing Assistant/CNA) checked on R4 for incontinence and was found with urine and feces-soaked brief with urine and feces leaked onto pads and then to linen with brownish discolored linen. A review of R4's bowel and bladder care plan document with interventions including cleaning the peri-area with each incontinent episode. Check upon rising, before, and after each meal, bedtime, and as needed (PRN). 2.R5 is a [AGE] year-old female having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R5 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R5 in her bed with an intense urine and feces smell. On 7/10/25 at 11:00 AM, V3 checked on R5 for incontinence and was found with feces-soaked incontinent brief with feces leaked onto incontinent pad and linen with brownish discolored linen. A review of R5's bowel and bladder care plan document, which includes interventions such as reminding, offering, and assisting with toileting needs as needed. 3.R6 is an [AGE] year-old female with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R6 is dependent on toileting hygiene. On 7/10/25 at 11:10 AM, observed the hallway close to R6's room with an intense urine and feces smell. On 7/10/25 at 11:10 AM, V3 checked on R6 in the presence of V2 (Director of Nursing), V4 (Nurse/LPN), and V13 (staffing coordinator). R6 was observed with smelly urine and feces-soaked dark brownish incontinent briefs that leaked on the incontinent padding and then onto linen. A review of R6's bowel incontinence care plan document to provide peri care after each incontinence episode. On 7/10/25 at 11:20 AM, V3 stated that she started her shift at 6:00 AM, and didn't get a chance to change some of her assigned residents including R4, R5, and R6. On 7/10/25 at 11:15 AM, V2 stated that the residents should get incontinent care at least every two hours and should have an odor-free environment. The facility presented an incontinence policy revised on 04/20/21document:Guidelines: Incontinent residents will be checked periodically per the assessed incontinent episodes or approximately every two hours and provided perineal and genial care after each episode. Residents Affected - Few 145779 Page 3 of 4 145779 07/15/2025 Elevate Care Palos Heights 12550 South Ridgeland Avenue Palos Heights, IL 60463

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a working kitchen exhaust fan and failed to replace the broken tiles. This applies to all 92 residents consuming food from dietary services.On 7/10/25 at 11:25 AM, observed kitchen with broken floor tiles (ceramic) throughout the kitchen. Observed that the exhaust fan above the stove is not working and the temperature around the stove area was unusually hot. On 7/10/25 at 11:32 AM, V6 (Dietary Aide) stated, I have been working in this kitchen for one and a half years. The kitchen floor tiles have been broken since I started here. On 7/10/25 at 11:35 AM, V7 (Cook) stated, Our exhaust fan was not working yesterday either. Air is working with two window units. The kitchen floor tiles were broken when I started here five years ago. It's not comfortable and safe to have uneven kitchen floors with floor tiles missing throughout the kitchen floor.On 7/10/25 at 11:30 AM, V5 (Dietary Manager) stated, Our exhaust fan over the stove is not working today and is not taking the heat out. Our maintenance is checking on the exhaust fan. Our maintenance is in the process of replacing broken tiles. It shouldn't be like that.On 7/10/25 at noon, V8 (Maintenance Director) stated, The exhaust fan failed this morning. We are in the process of renovating the whole place. On 7/10/25 at 12:45 PM, V8 added, As a maintenance director, I focus mainly on the heating/air conditioning system. We are in the process of replacing the broken tiles all over the kitchen floor. The facility presented Environmental Services Policy (undated) document: It is the policy of the facility that it is constructed, equipped and maintained to carry out the functions of all services and to promote the health and safety of residents, personnel, public, and in compliance with all applicable Federal, State and Local regulations.On 7/11/25 at 11:01 AM, V2 (in an email communication) stated that 92 residents consume food from the dietary service. 145779 Page 4 of 4