Inspection·March 5, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow therapy recommendations, and fall prevention interventions to include use of a manual wheelchair and keeping the call light within reach. This affected two of three residents (R2, R3) reviewed for safe use of a motorized wheelchair and fall prevention interventions. This failure resulted in R2 using the motorized wheelchair resulting in a fall incident requiring R2 to be sent to the local hospital for treatment of a right frontal scalp hematoma. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of muscle wasting, history of falling, acute kidney failure, reduced mobility, weakness, fracture of right pubis, right artificial hip joint, osteoarthritis, and dysphagia. R2's fall report dated 1/13/24 documents: The nurse heard a loud noise in the resident's room. The nurse witnessed resident on the right side near the foot of his bed and appeared to have fallen from electric wheelchair. Under resident description: Resident stated he was attempting to move his power chair and fell. Under injury abrasion to top of scalp and laceration to left hand. Under mental status oriented to person only. Under predisposing environmental factors document equipment or device. On 1/14/23 fall root cause documents: Resident stated he was sitting up in his motorized wheelchair when he was attempting to move his chair and fell out after leaning too far. On 2/13/24 at 1:17pm, V5 (therapy director) stated when R2 was participating in therapy. R2 had a motorized wheelchair he had used in the past for mobility. At time of therapy the use of the motorized wheelchair was not attempted due to medical concern related to cognition and functional ability. R2 had poor sitting balance and required a mechanical lift for transfers which would contradict the use of a motorized scooter. R2 was utilizing a manual wheelchair during therapy. When there are any changes to a resident's assistance devices, therapy would inform the unit supervisor of the changes. R2's motorized wheelchair should have been removed by staff to ensure R2 did not use it. V5 stated the therapy department did not remove R2's chair and was unsure if it was still in R2's room after discharge from therapy. R2 should have been utilizing a manual wheelchair. On 2/15/24 at 4:00PM, V17(CNA) was the assigned aide to R2 at time of fall on 1/13/24. V17 stated she recalls R2 being in his motorized wheelchair at start of her shift in common area. A little later, R2 was on the floor in his room on the mat. V17 was unable to recall any other details of fall. V17 stated she was not sure if R2 fell from the motorized wheelchair or if the motorized wheelchair was in the room at time of fall. V17 stated she does not think she assisted R2 with going back into the bed after her shift prior to the fall. V17 does not recall anyone saying R2 could not use the motorized wheelchair. On 2/13/24 at 2:40PM, V9 assistant director of nursing (ADON/third floor supervisor) stated if there were changes in resident's assistive devices use or mobility, therapy would communicate with me or at stand-up meeting in the morning. V9 does not recall ever being told that R2 could not use the motorized wheelchair. If it was communicated that R2 could not use the device, it would be removed from the room. R2's therapy notes dated 12/16/23 documents under initial assessment wheelchair mobility: wheel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145967 If continuation sheet Page 2 of 5 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 145967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Country Club Hill 18200 South Cicero Avenue Country Club Hills, IL 60478 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 - Actual harm Residents Affected - Few fifty feet with two turns- not attempted due to medical conditions or safety concerns; type of wheelchair or scooter used - motorized; wheel one hundred fifty feet- not attempted due to medical conditions or safety concerns. Under balance: Patient sits unsupported for thirty seconds with feet flat on floor and no back support- No; amount assisted needed to sit at edge of bed- moderate assistance; time patient can sit unsupported- unable seconds. Under reason for therapy clinical impressions: Based upon examination of patient's body regions, systems and structures, patient presents with strength impairments, safety awareness deficits, balance deficits and muscle disuse and in consideration of history, personal factors and functional abilities documented in this evaluation summary. Patient requires skilled therapy. Physical therapy Discharge summary dated [DATE] documents under wheelchair mobility patient will increase ability to safely propel in wheelchair one hundred fifty feet with supervision or touching assistance on level surfaces. At discharge required partial to moderate assistance. Under wheelchair mobility type of wheelchair manual. R2's hospital record dated 1/13/24 documents CT/computed tomography scan of head impression: no acute traumatic injury in brain or spine. No acute intracranial hemorrhage. Small right frontal scalp hematoma without underlying calvarial fracture. R3 was admitted with the diagnosis with muscle wasting and atrophy, reduce mobility, lack of coordination, abnormal posture, weakness, hemiplegia affecting left non-dominant side. Minimal data set section C (cognitive status) - brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. Section GG documents: 03- roll left and right - 03 indicated partial/moderate assistance- helper does less than half the effort. Helper lifts, hold or supports truck or limbs but provides less than half the effort, (functional abilities and goals/functional limitation in range of motion) documents: 1 upper/lower extremity - 1 indicates dependent- helper complete all the activities for the resident. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, place and time stated, R3 said, V13 (cna) disconnected his call light from the wall. R3 stated, he fell due to reaching for his call light. On 2/13/24 3:04pm, V11 (nurse manager) stated, R3 was reaching for something and had a fall. V11 stated we spoke with V13 about R3's call light not being answered. On 2/13/24 at 3:38pm, V12 (guest relations) stated, R3 who was alert and oriented times three, stated, he R3 fell out of bed attempting to reach the call light. R3 has never made an allegation of falling out the bed before or the inability of reaching the call light. V12 stated, if R3 stated it happened then it did. After speaking with R3, V12 stated, she completed a concern form related to V13 not having the call light within reach. Concern/Compliment form dated 1/29/24 document: V12 took the report- R3 was educated on call light use. Staff made aware resident (R3) call light is within reach when rounding. R3's care plan initiated 1/26/24 documents: R3 was at risk for fall related to deconditioning and weakness r/t left hemiplegia, lumbar stenosis, and sciatica. Interventions: Keep call light and desired personal items within reach. Fall incident dated 1/29/24 documents: Alerted to residents (R3) room, resident sitting on buttock on the floor next to bed. Resident stated, I slid out of bed while attempting to turn over. Resident assisted back to bed with mechanical lift. Mental status: oriented to person, place, and situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145967 If continuation sheet Page 3 of 5 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 145967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Country Club Hill 18200 South Cicero Avenue Country Club Hills, IL 60478 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 Predisposing physiological factors: gait imbalance and impaired memory. No witnessed found. Level of Harm - Actual harm Fall prevention program dated 11/28/12 documents: to assure the safety of all residents in the facility. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145967 If continuation sheet Page 4 of 5 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 145967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Country Club Hill 18200 South Cicero Avenue Country Club Hills, IL 60478 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on interview and record review, the facility failed to follow the physician's orders for one resident with a diagnosis of osteoarthritis by not applying a prescribed lidocaine pain patch (local anesthetic) as ordered. This affected one of three residents (R3) reviewed for pain. This failure resulted in R3 complaining and enduring left knee pain with a pain score of ten out of ten for over seven hours (zero equals no pain, five equals moderate pain, and ten equal excruciating pain). Residents Affected - Few Findings Include: R3 brief interview for mental status dated 01/30/24 documents a score of fifteen which indicates cognitively intact. R3's physician order summary start date 2/8/2024 documents: Lidocaine external Patch 4% (lidocaine) -Apply to left knee and low back topically one time a day for mild pain and removed per schedule. Physician progress note dated 2/12/24 documents: R3 has a diagnosis of Osteoarthritis (OA) and left knee arthroscopy. On 2/13/24 at 1:28pm, R3 who was assessed to be alert and orient to person, time and place stated, he did not get his pain patch applied to his left knee this morning. R3 stated, his pain was a 10 out of 10. R3 stated, the pain patch did not come off because it was not applied. R3 was observed in bed while V33 (cna) and V34 (cna) provided ADL/activities of daily living care. R3 was observed without a pain patch on his left knee, no patch was observed stuck to the inside of R3's pajama or on R3's bed pad/sheets. V33 (cna) and V34 (cna) both stated, R3 did not have a pain patch on his left knee nor was the patch on R3's clothing or bed/bedding. V34 said, she provided care to R3 all day. R3 did not have a patch on his left knee this morning. On 2/13/24 3:04pm, V11 (nurse manager) stated, the nurse should have applied R3's pain patch. V11 stated, she would expect physician orders to be followed. On 2/21/24 at 2:37PM, V32 (nurse), stated, she applies R3's pain patch to his lower back and knee every time she works. The administration of R3's pain patch will be recorded on the medication administration record and on the location administration report. Location of Administration report dated 2/13/24 documents: V32 (nurse) administered, topically to back -lower, mid/ thoracic (left) Pain Management Policy dated 11/28/12 documents: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145967 If continuation sheet Page 5 of 5