Inspection·September 16, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident rights to be free from physical abuse by staff. This failure affected two (R1 and R2) of four residents reviewed for abuse and resulted in R1 sustaining swelling and redness to her left eye and being transferred to a local hospital to rule out orbital fracture and R2 sustained redness to his face after being slapped by a staff. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2020, past medical history includes, but not limited to: cerebral palsy, spastic hemiplegic cerebral palsy, paroxysmal atrial fibrillation, vascular dementia, essential primary hypertension, encounter for attention to colostomy, anemia, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, hypotension, etc. On 9/5/2024 at 10:25AM, R1, who just returned from the hospital was observed in her room, awake and alert and was being assisted with ADL (activities of daily living) care by V10 (restorative aide). R1 was asked why she went to the hospital, and she R1 stated, the two CNA's (certified nursing assistant) hurt me, one was on the right side and was twisting my hand and fingers, the other was on the left side hitting me with the remote control. R1 tried to demonstrate what happened by twisting surveyor's fingers and used her bed remote control to demonstrate how the CNA hit her face. R1 was noted with some dark purplish bruising to her right hand, some redness to her left cheek under the left eye and a little swelling around the left eye. Progress note dated 8/31/2024 at 9:32AM documented that R1 was noted with swelling and discoloration to her left eye, patient complained of some pain and pain meds were given. Attending physician who was on ground was notified, ordered for the resident to be sent out to a local hospital. Physician progress note dated 8/31/2024 at 12:10PM states in part: patient seen and examined, patient is complaining of swelling and pain on the left eye patient stated that somebody had hit her. No fever or chills, patient states she cannot move her left eye, will send patient to the hospital for evaluation of possible orbital fracture. Facility reported incident dated 8/31/2024 documented in part that R1 was noted with discoloration to her left eye, and she described the two staff that she alleged caused her the injury while providing her with ADL care. Police report dated 8/31/2024 documented that police responded to the facility for a delayed battery report. In the report, R1 was named as the victim and V6 (CNA) and V7 (CNA) named as the suspects. (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 3 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 09/16/2024 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)