Inspection·July 11, 2024

F 0686 R7's weight summary documented that R7 weighed 186.6 lbs on 6/5/2024 and 182.2lbs on 07/10/2024. Level of Harm - Minimal harm or potential for actual harm R7's (05/01/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 12. Indicating R7's mental status as moderately impaired. Section M. Skin Condition. M0100. Determination of Pressure Ulcer/Injury Risk: A. Resident has a pressure ulcer/injury. M1200. Skin and Ulcer/Injury Treatments: B. Pressure reducing device for bed. Residents Affected - Few The (undated) pressure injury prevention documented, in part Definition: a pressure injury is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. Pressure injuries usually occur over Bony prominences and are staged to classify the degree of tissue damage observed. Skin care and early treatment. Pressure Relieving/Reduction Mattresses. All residents assessed to be at risk for skin breakdown should be placed on a pressure redistributing bed or mattress. This can range from alternating pressure mattress, low air loss. It is important to check that the low air loss mattress is set to the appropriate resident's weight and functioning properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 2 of 7 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 Based on observation, interview and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by failing to place a resident with a pressure wound on EBP to prevent the potential spread of multidrug resistant organisms. This failure affects one resident (R5) and the potential to affect three additional residents (R9, R10, R11) on the sample list of 11. Residents Affected - Some Findings include: The (07/08/2024) list of residents seen by V4 (Occupational Therapist) after seeing R5 include R9, R10 and R11. On 07/08/2024 at 11:46am, R5 stated I (R5) have a wound on my butt. This surveyor double checked R5's doorway. There was no EBP sign posted or Personal Protective Equipment (PPE) available outside of R5's room. On 07/08/2024 at 11:50am, V4 (Occupational Therapy) brought a rolling walker inside R5's room. V4 was wearing a mask, placed the rolling walker by R5's doorway and donned gloves. V4 walked towards R5, opened R5's milk carton, raised R5's bedside table, and repositioned R5 on bed. V4 removed V4's gloves and donned another pair of gloves. V4 then adjusted R5's table, touched food items on R5's bed side table, touched R5's spoon and stated Let's see how you do. V4 touched R5's small container for desserts and asked R5 You want me to take them (referring to R5's food tray) away? V4 brought out R5's food tray. On 07/08/2024 at 11:59am, V4 stated she (R5) had few pieces of chicken left on the plate. I (V4) set the cake on her (R5) table. She (R5) just got here, and I (V4) want to do the evaluation if she (R5) can feed herself. On 07/08/2024 at 12:04pm, surveyor requested V3 (Agency Registered Nurse) to check R5's room for EBP sign and PPE bin. V3 stated there is no EBP sign and no PPE bin. Resident on EBP are residents who have IV (intravenous) lines, urinary catheters, gastrostomy (g-tubes), dialysis, chemotherapy, and wounds. The purpose of placing residents on EBP is to avoid introducing infection to residents or staff. That is something new that we implemented. On 07/08/2024 at 12:05pm, inquired about R5's wound. V4 stated I (V4) am not aware she (R5) has wounds. She (R5) said that her (R5) butt is sore. I (V4) did not see the EBP sign and there is no PPE bin. Did I (V4) miss to see them? V4 did a double look on R5's doorway and stated there were no EBP sign or PPE bin. On 07/08/2024 at 2:07pm, V10 (Wound Care Nurse/LPN) stated we do have a policy for residents on enhanced barrier precautions. EBP is for residents with wounds, tracheostomies, urinary catheters, dialysis and g-tubes. The staff need to put on a gown and gloves to keep the contamination down, because residents have wounds, and we don't want any transfer or exchange of germs from residents to staff and staff to residents. On 07/08/2024 at 2:17pm by R5's doorway, V10 (Wound Care Nurse/LPN) stated I (V10) don't see an EBP (Enhanced Barrier Precautions) sign posted by her (R5) door. There is no PPE bin or PPE organizer by her (R5) door. She (R5) has a wound; she (R5) should be on EBP. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 3 of 7 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/08/2024 at 2:39pm, V11 (Infection Preventionist/LPN) stated I (V11) have 38 residents on EBP with urinary catheters, tracheostomies, g-tubes, chronic wounds, wounds and some with history of Multi-Drug Resistant Organisms (MDRO). The policy is, when they (residents) are getting care from staff, staff are supposed to wear a gown and gloves when providing high contact direct patient care like transferring a resident, providing perineal care, g-tube care, hanging g-tube feeding, suctioning, urinary catheter care, and wound care. Staff are expected to wear a gown and gloves when scooting up or repositioning a resident on EBP. An EBP sign, taken from the Center for Disease Control (CDC) website should be posted and the PPE bin should be accessible to provide those entering the EBP rooms with gowns and gloves upon entry to the residents rooms. The importance of putting the EBP sign is to direct the staff to use PPE for each resident assigned to them who are on EBP. The purpose of having a PPE bin outside the room is to have PPE accessible to staff. On 07/08/2024 at 2:47pm outside of R5's room. Surveyor informed V11 that R5 has a wound. V11 stated she (R5) is a new admission last Friday (07/05/2024) and I (V11) already left the facility. The process is once I (V11) ran the report, I (V11) go check the resident if they have anything that requires EBP. Once I (V11) am aware, then that is the time to put the sign and PPE bin. This surveyor inquired if staff has to wait for V11 to work the next business day to post the EBP sign and provide PPE bin to R5. V11 stated there should be an EBP sign posted and PPE bin available upon R5's admission. On 07/10/2024 at 1:22pm, V2 (Director of Nursing) stated the policy is any resident who has a urinary catheter, IV, dialysis, colostomy or wound should be on EBP. For any high contact care to residents, staff are expected to wear gloves and gown. If a staff has to reposition a resident, the staff need to wear gown and gloves. It is expected to have an EBP sign posted by the door and PPE bin or organizer by the door of the resident. The purpose of the EBP sign is to notify the staff that the resident is on enhanced barrier precautions. The purpose of the PPE bin is to have accessible PPE for staff to wear. We should have inserviced the nurses that when staff noticed a resident qualifies to be on EBP, to implement the EBP upon admission. The purpose of EBP is to prevent the spread of infection. R5's census list documented that R5 was readmitted at the facility on 07/05/2024. R5's admission Record documented that R5's diagnoses (include but not limited to) pressure ulcer of sacral region, stage 3. R5's (On or After 07/09/2024) Medication Review Report documented, in part Enhanced Barrier Precautions r/t (related to) wound. Order Date: 07/08/2024. Start Date: 07/08/2024. Sacrum: Cleanse with NSS (normal saline solution) or wound cleanser. Apply Honey gel to wound bed and cover with hydrocolloid dressing every day shift every Tue(sday), Thu(rsday), Sat(urday) and PRN (as needed). Order Date: 07/06/2024. Start Date: 07/06/2024. Of note, enhanced barrier precaution was ordered 3 days after R5's admission. R5's (Assessment Date: 07/06/2024) Wound Assessment Details Report documented, in part Date Identified: 07/05/2024. Wound Sacrum. Present on admission. General. Exudate (wound drainage). Type: serosanguineous (a clear, blood-tinged drainage). R5's (07/05/2024 18:28 (6:28pm) documented, in part Admission. dressing observed to sacrum(.) removed noted open area cleanse and dressing applied. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 4 of 7 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 The (undated) Enhanced Barrier Precautions by floor did not include R5. Level of Harm - Minimal harm or potential for actual harm The (07/11/2024) email correspondence with V2 (Director of Nursing) documented, in part Resident condition/s that warrant/s EBP. EBP isolation and reasons are listed below and not limited to: Wounds. Residents Affected - Some The (07/11/2024) email correspondence with V2 documented, in part we do not have EBP care plan for (R5). The (01/15/2024) enhanced barrier precautions (EBP) document, Purpose: To minimize the risk of acquiring, transmitting, or complications resulting from Multidrug Resistant Organism (MDRO) colonization among residents in this setting. Equipment needed: gowns, gloves, and Room Notification signage. Guidelines: Staff will require the use of personal protective equipment (PPE) for high risk activities such as any situation where expected contact of blood, bodily fluids, skin breakdown, or mucous membranes will be encountered. Persons expected to encounter this circumstance are to don PPE (gown and gloves) in accordance with the activity that will be encountered when caring for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 5 of 7 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 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 ensure the availability of adequate clean bed linen due to inadequate supply of new bed linens and laundry equipment malfunction. This has the potential to affect all 197 residents who reside in the facility. Findings include: On 7/9/24 10 AM the 3rd floor was observed with no bed linens on 2 clean linen carts located in the corridor. 3rd floor clean linen room was observed with no sheets stocked on shelves. On 7/9/24 10:20AM the 2nd floor was observed with no linens on 3 clean linen carts. The 2nd floor clean linen room had no sheets. On 7/9/24 10:30AM the 1st floor was observed with no linens on 2 clean linen carts. On 7/9/24 at 11:44AM the basement supply storage room used to store new bed linens was observed with no new bed linen. On 7/9/24 at 11:50AM the laundry machine room was observed with 3 washing machines. One washing machine was not functioning and there were no clean bed sheets observed in the laundry area. On 7/9/24 10:15AM V17 (3rd floor CNA) stated we usually have linens on floor however they didn't bring them up yet. On 7/9/24 V19 (2nd floor CNA) stated they are not bringing up the linens, I am out of linens. On 7/9/24 at 10:52AM V18 (Housekeeping Manager) stated we do not have any new linens in stock. We ordered linens but they have not yet arrived. We are washing linens and then we bring them up to the floors. At this time there is a washer down and we cant get them up to the floors in a timely manner. On 7/10/24 at 11:17AM V28 (Laundry Aide) stated since the washing machine went out about 5 days ago I cannot wash the soiled sheets and get them on the floors on time. There are no new sheets in stock to be able to get sheets up on the floors. I don't know how long the facility has not had new stock of linens. On 7/10/24 at 11:24AM V1 (Administrator) stated we ordered a large amount of sheets and they have not yet been delivered. There are no new sheets in the facility at this time. The staff are throwing sheets out and we have had issues with keeping adequate sheets stocked in the facility. One of the washing machines went out over the weekend. The laundry staff could not wash the linens and get them up on the floor. We did not have new linens in stock at the time to get on the floors. The service company got the machine going today. Today all three machines are functioning. The facility's Midnight Census Report for all units on 7/8/24 documents 197 residents reside in the facility. Facility policy titled Preventative Maintenance Laundry states including: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 6 of 7 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 145970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Windsor Park 2649 East 75th St Chicago, IL 60649 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 0921 Washers and dryers have preventive maintenance functions performed by the laundry and Level of Harm - Minimal harm or potential for actual harm maintenance staff based upon recommendations of the manufacturer. Checklist is completed by staff, signed, and dated. The Environmental supervisor will review Residents Affected - Many the checklist, then sign and file the checklist. Any repairs necessary will be documented and given to the Environmental Supervisor. A report is made to the Safety Committee at the scheduled meeting. Repairs that require capital expenditure will be documented by the maintenance staff or maintenance supervisor and discussed with the Administrator. Staff follows the maintenance schedule for clothing washers and dryers as established by the Environmental Supervisor. Facility policy titled Linen Handling Principles - Nursing includes the following: 13. Laundry personnel shall be responsible for assuring adequate amounts of clean linen and personal clothing are available on each nursing unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 7 of 7