Inspection·November 10, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many handrails, loose guard rails cover and tile missing around shower faucet. Used and open soap bottles on floor, debris, clutter, shower bed and commode sitting in the middle of walkway. Soiled wet and used linen on shower floor. Sign on one entrance of SPA room with out of order sign, but no out of order sign on other entrance of SPA room. On 12/8/2024 at 12:26 pm, V5 (CNA Restorative Aide) stated, residents get showers 2x a week but can get more. There are 2 shower rooms on each floor. All 2nd floor residents use the shower rooms on this floor, but if there is a problem with showers on this floor, we will take the resident to another floor. If there is broken equipment or something is broken in the shower, we put in computer or call maintenance to get fixed. On 11/8/2024 at 12:37pm, 2nd floor SPA/shower room stall 1 shower does not work, small amount of water dripping through hose, stall 2 missing hose, stall 3 shower head water sputters while running, adult opened used wipes sitting on handrail, missing tile, needle box holder with used razors hanging out of box, and accessible to resident. Tub room with dirt and equipment on the floor, shower head gushing water out pipe over shower, shower head not working. Debris and dirt on floors. On 11/8/2024 at 12:53pm, surveyor observation of SPA room across R9's room. Observed stall 1 with ripped and soiled with debris on curtain, stall 2 with soiled curtain with debris on curtain, stall 3 ripped and soiled with debris, dirty floor with clutter. On 11/8/2024 at 12:54pm, V7 (CNA) stated, rooms are cleaned every day, shower is cleaned after a resident takes a shower then shower is cleaned. On 11/8/2024 at 1:05pm, V8 (Housekeeper) stated, rooms are cleaned every day and shower rooms are cleaned in the morning and sometimes after a shower. On 11/8/2024 at 1:18pm, V9 (Restorative Aide) stated, there are 2 shower rooms on each floor with 3 stalls. There is a set schedule for resident showers. Residents get showers 2x a week and PRN (when necessary). Residents that have a shower in their room have shared their shower with another resident. Residents can get a bed bath if requested. Resident rooms and shower rooms are cleaned daily by housekeeping. On 11/8/2024 at approximately 1:30pm, V10 (Director Environmental Services) stated, shower rooms are cleaned every day and sometime the housekeeper will go back during the day to check. If there is anything that is broken or needs to be fixed, maintenance is notified. On 11/8/2024 at 1:42pm, V11 (Maintenance Director) stated, staff will call to let me know if something is broken or will put through the computer. Surveyor asked V11 how long it takes for equipment to get fixed. V11 stated, it depends on the problem and if we have the part. If we have the part, we fix if not we order the part if we do not have the part. Surveyor asked V11 what the meaning of the sign is posted Temporarily Out of Service on some of the shower doors. V11 stated, all shower rooms are functioning, but we still need to replace the tile behind the shower valves, caulk and reseal. The residents are taking showers in all six of the shower room, that sign does not mean the shower cannot be used, residents are using the showers. You can see the floors are wet and linen is on the floor. On 11/8/2024 at 1:48pm, surveyor and V11 tour of facility shower rooms. Third floor shower room, 1st stall no shower head, hose hanging. V11 stated, will put in tile and repair shower valve, need to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 2 of 4 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 11/10/2024 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 replace the tile. Stall 2 no shower holder, stall 3 no hose or shower head. Two of three showers working. V11 stated, staff let us know by word of mouth or put in a work order through the computer if there is a problem with showers we will fix. Surveyor observed debris and clutter in room, shower torn, dirty and stained curtains. Toilets handrail missing. V11 stated, I did not know handrail was broken. V11 stated, once a month we do equipment rounds. Surveyor asked, if checking shower rooms was included in monthly rounds. V11 stated, no. They let us know if something is broken and we take care of it. Surveyor asked, V11 if residents should use the shower rooms with all broken tile chips, debris, ripped and tattered shower curtains. V11 stated, residents can still come in and shower. Observed soiled towels, sheets and clothes and shoes in shower room and equipment sitting in the middle of the floor. 3 East shower room observed with missing grout, dirty floor, debris and clutter, soiled and stained shower curtains. V11 stated, I do not think anyone uses the tub room, the water is off for this tub. 2nd floor across from dining room, stall 1 shower does not work, V11 stated, need new shower head, stall 2 tile broken and V11 stated, will repair it, stall 3 water sputtering out of shower head. V11 stated, tile has been broken for a long time. 2 East shower room shower pipe gushing water and air vent broken, V11 stated, will replace. One of Three shower hoses working. 2 [NAME] shower room One of three showers working. 1 East shower room [ROOM NUMBER] of 3 showers working, missing handrail. Shower curtains soiled and stained, shower room cluttered with equipment and debris on floor. 1 [NAME] shower room with soiled and stained shower curtains, bottles of used soap on floor, used soiled towels and linen on floor. On 11/8/2024 at 2:31pm, tour with V1 (Administrator) and V2 DON (Director of Nursing). V2 stated, shower rooms are still being used. V1 stated, showers need to have shower hooks, the person that purchased the shower hose and heads did not get holders. Shower curtains are changed by housekeeping. Housekeeping is responsible for cleaning shower rooms and CNAs clean shower room between the residents. CNAs are to make sure towels, soap, linen is taken out then housekeeping come in and mop showers and change shower curtains. We use computer system to notify maintenance of broken equipment or can call on walkie talkie. Each nursing station has a walkie talkie. V1 stated, company consultant does walk through with maintenance, housekeeping director. Maintenance and housekeeping director do daily walk through as well. I (V1) am responsible to make sure they are doing what they are supposed to do. On 11/9/2024 at 10:37am, 1st floor shower rooms still with dirty linen and debris. Tub room remains dirty. On 11/9/2024 at 10:44am, V16 (CNA) stated, there are two shower rooms on each floor with 3 stalls in each room. All the shower rooms are working. V16 stated, CNAs clean up the shower room after the resident leaves and housekeeping cleans shower room every day. I throw towels down the chute; soiled diapers go in the soiled utility room. I clean up after myself. That is what is supposed to do, but I cannot speak for anyone else. On 11/9/2024 at 11:00am, 2 East shower stalls with soiled and stained shower curtains. 2 [NAME] shower room dirty and used wash cloth on floor. On 11/9/2024 at 11:13am, 3rd floor V18 (LPN) stated, housekeeping cleans the showers once a day. If the showers are not working, we take the residents downstairs. The shower room is supposed to be cleaned after each resident. We take a plastic bag in with us and put dirty linen and towels in the plastic bag and throw down the chute. On 11/9/2024 at 11:17am, V19 (CNA) stated, showers are scheduled and if a resident refuses a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 3 of 4 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 11/10/2024 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 shower, I tell the nurse and the nurse will talk to the resident to try and get them to take a shower. CNAs clean up and it is listed on the special assignment. Housekeeping cleans the resident showers every day and will clean mirrors and mop every day. When I am done with giving resident shower, I put everything in a plastic bag and put down the chute. We (CNAs) clean up the shower after the resident. Facility Assessment Tool for Elevate Care Windsor Park 2023-2024 states (in part): Requirement nursing facilities will conduct, document, and annually review a facility-wide assessment includes resources the facility needs to care for their residents. Purpose to determine what resources are necessary to care for residents competently during both day-to-day operations. Make decisions to provide services to the residents in your facility. Part 2: Services and Care We Offer Based on our Resident Needs, activities of daily living bathing and showers, Infection Prevention and control, prevention of infection. Physical environment and building/plant needs: 3.8 physical resources, processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents. Physical equipment, bathroom safety bars, bathing tubs. Director of Environmental Services Job Description Summary states (in part): The primary purpose of the Director of Environmental Services is to plan, organize, develop, and direct the overall operation of the Housekeeping Department, to assure that our facility is maintained in a clean, safe, and comfortable manner. Meet with housekeeping personnel on a regularly scheduled basis and solicit advice from inter-department supervisors concerning the operation of the housekeeping department; assist in identifying and correcting problem areas, and/or the improvement of services. Assist in standardizing the methods in which housekeeping tasks will be performed. Make daily rounds to assure that housekeeping personnel are performing required duties and to assure that appropriate housekeeping procedures are being rendered to meet the needs of the facility. Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained and operable to perform necessary duties and services. Maintenance Director Job Description Summary states (in part): The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. Repair facility/resident property as necessary. In the event of inability to repair coordinate with outside vendors to make repair or replace. Also ensure that services provided by outside vendors are properly completed/supervised in accordance with contracts/work orders. Keep abreast of economic conditions/situations and recommend to the Administrator adjustments in maintenance services that assure the continued ability to provide a clean, safe and comfortable environment. Ensure that supplies, equipment, etc., are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator. Place orders for equipment and supplies as necessary or as may be required. Facility Policy (Dated 7/01/13) Title: Preventative Maintenance: Nursing Unit Policy states (in part): All non-medical equipment located on the nursing unit outside of the resident rooms will have preventive maintenance on either a monthly or annual basis as scheduled. A. Any repairs will be documented and given to the Environmental Supervisor. The facility will complete noted repairs. Non-Medical Equipment Includes: Electrical outlets in nursing station, shower rooms, medication room, utility rooms, dining room, and corridors. Shower chairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145970 If continuation sheet Page 4 of 4