Inspection·May 24, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify and treat pressure ulcers for a resident dependent on staff for care. This affected one of three residents (R4) reviewed for pressure ulcers. This failure resulted in R4's pressure ulcers not being found/treated until they were an advanced stage on 10/17/23, 3/21/24 and 4/11/24. Residents Affected - Few The findings include: R4's face sheet printed on 5/24/24 shows that R4 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Acute and Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Ventilator, End Stage Renal Disease, Dependence on Renal Dialysis, and history of Sudden Cardiac Arrest. R4 was discharged from the facility on 4/29/24 to the hospital and was not in the facility on 5/24/24. R4's Shower Form dated 10/17/23 shows that R4 has skin tears to her sacrum, posterior right thigh, and right ear. A handwritten comment on this form states, open areas noted. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Deep Tissue Injury measuring 7 x 8 x Unknown cm that was 90% deep maroon in color and 10% pink or red non-granulating tissue. (R4 was last readmitted to the facility from the hospital on 9/11/23) R4's Initial Wound Physician Progress Note dated 10/20/23 states, Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 cm length x 4 cm width x 0.1 cm depth . There is a light amount of serosanguineous drainage noted which has no odor. Wound bed has no granulation, 100% slough . On 5/24/24 the facility provided two Shower Forms both dated 3/21/24. The first form shows that R4 has four open areas, sacrum, left elbow, right heel, and left heel. This form also shows that R4 has a G-tube (Gastrostomy). This form is signed by a CNA and a nurse. The second Shower Form is dated 3/21/24 and shows that R4 has an open area on her right elbow and is signed only by a nurse. R4's Wound assessment dated [DATE] shows that R4 developed a facility acquired Unstageable wound to her left elbow measuring 1 x 1.5 x Unknown cm that is described as 50% bright pink or red and 50% necrotic soft, adherent. (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: 145967 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 05/24/2024 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)