Elevate Care Country Club Hill

Inspectors wroteBased on interview and record review, the facility failed to supervise one resident that was identified as a high risk with severe cognitive impairment and a history of falls who required one person assist with transfers. This affected one of three residents (R1) reviewed for falls and supervision. This failure resulted in R1 having an unwitnessed fall while self-transferring sustaining left cervical spine (C1) and (C5) fracture. Findings Includes: R1 current diagnoses include but not limited to Alzheimer Disease, Parkinson's Disease, Dementia and a history of falling. R1Minimal data set section C (cognitive patterns) dated 4/22/26 documents a score of three which indicates severe cognitive impairment. Section GG (functional abilities) documents: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its incontinence care guidelines by failing to provide timely incontinence care to dependent residents. This applies to 4 of 6 residents (R3, R4, R5, and R6) reviewed for incontinence care in a sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the LALM (Low Air Loss Mattress) was on the right setting (while in use) and failed to implement preventive interventions to prevent further decline for two (R6 and R7) of four residents. These failures affected R6 and R7 and have the potential to affect all 39 residents using LALM in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin medication was stored in a locked medication cart when not in visual proximity of the nurse. This failure affected one (R3) of four residents whose insulin medication was left at bedside without a physician order. This failure has the potential to affect 37 residents residing on the 2nd floor in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall prevention intervention for a resident at risk for falls. This failure affected one (R5) resident reviewed for falls in the total sample of 5 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement fall preventive measures for a resident who is a 2 person transfer assist due to increased weakness and behaviors. This deficiency affects one (R1) of three residents reviewed for Falls prevention program. This failure resulted in R1 being hospitalized and treated for a Closed Fracture of Left ankle.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary assistance for one dependent resident (R149) in accordance with care plan by failing to complete weekly shower/skin assessment as ordered. This failure affected one (R149) of six residents reviewed for Activities of Daily Living (ADL) care. R149 developed a hematoma to her right great toe at the facility, complaint of pain where it was noted R149's wound was infected, and an x-ray revealed a fracture to the right great toe. R149 was treated with oral antibiotics for seven days.

Inspectors wroteBased on interview and record review the facility failed to administer medication as ordered for one resident (R77) reviewed for medication administration. This failure affected one resident and has the potential to affect all residents residing on the 2nd floor.

Inspectors wroteBased on interview and record review, the facility failed to transcribe physician orders for comfort care medications for a resident admitted to hospice care services. This failure affected one (R1) of five residents reviewed for physician orders and resulted in R1 having untreated pain for several days before expiring in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their grievance policy by not acknowledging a concern written by a resident representative. This failure affected one of one (R1) resident reviewed for grievances.

Inspectors wroteBased on interview and record review the facility failed to ensure resident safety by failure to provide two persons assist to a totally dependent resident (R121) when providing incontinence care. This failure resulted R121 falling from bed that required a visit to the hospital for evaluation and repair of a laceration to the scalp which needed three staples. This deficiency affects one (R121) of three residents in the sample of 32 reviewed for Resident safety/Fall Prevention Program.

Inspectors wroteBased on interview and record review the facility failed to prevent a pressure injury from developing for an at-risk resident for 1 of 3 residents (R4) reviewed for pressure in the sample of 8.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to implement a treatment plan for (R4) who was identified as very high risk for skin break down, admitted with an opening on the penile shaft, excoriation on the penile head/tip with the penile prosthesis in an erectile position for twenty-two days. This failure resulted in R4 sustaining a facility acquired full thickness, moisture associated skin dermatitis (MASD) measuring 8.00 centimeters (cm) x 3.00 (cm) x 0.10 (cm) (L x W x D) for one of three reviewed for wound care in a sample size of ten. Findings Include: On 7/19/24 at 12:58PM, V6 (treatment nurse) stated, MASD is caused by moisture (urine, stool, sweat and or body fluids) which would cause a break in skin due to repetitive movements or friction. R4 was admitted with a penile implant that was fixed and erect. It would not go down. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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). 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: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide incontinence care for a resident identified as dependent on staff assistance with toileting. This affected one of three (R3) residents reviewed for incontinence care. This failure resulted in R3 not being provided incontinence care for over six hours. Findings Include: R3's minimal data set section C (cognitive pattern) dated 1/30/24 documents a score of fifteen which indicates cognitively intact. Section GG (functional abilities and goals section) documents: 01 for toileting hygiene. 01 indicates dependent- helper does ALL of the effort. Resident does none of the effort to complete the activity. Section H (Bladder and Bowel) dated 1/31/24 documents: R3 was always incontinent. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene before administering medications to three (R64, R79, and R146) of six residents reviewed for medication administration and before providing juice and lotion to two (R9, R20) of five residents reviewed for activities in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to stabilize the indwelling urinary catheter for one resident (R103) of six residents reviewed for catheters in the sample of 33.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to implement effective fall prevention interventions and determine the root cause of previous falls to prevent and/or reduce the risk of residents falling. This affected three of three residents (R6, R4, and R8) reviewed for fall prevention interventions. This failure resulted in R6 falling from bed while staff was providing direct care and leaving resident unmonitored returning to find R6 on the floor. R6 was sent to the hospital assessed to have sustained a bilateral subarachnoid hemorrhage.

Inspectors wroteBased on interviews and records reviewed the facility failed to prevent staff from being verbally abusive. This affected one of three (R4) reviewed for verbal abuse.

Inspectors wroteBased on interviews and records reviewed the facility to implement their abuse policy by not immediately reporting and removing a staff member from resident care after an allegation of verbal abuse. This affected one of three residents (R4) reviewed for abuse policy.

Inspectors wroteBased on interview and record review, the facility failed to prevent or determine how an injury of unknown origin to the left femur for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an injury to the left femur with the bone exposed through the left thigh wound causing the resident to be sent to the local hospital for treatment. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. A Nursing note dated 11/7/23 documents the floor nurse (V8) was informed by the wound care nurse (V4) that R1's left thigh wound was bleeding. Upon observation, R1 was awake and in no distress. Bleeding was observed to the left thigh wound. The wound care nurse applied pressure to the site. [...]

Inspectors wroteBased on interview and record review, the facility failed to order and provide wound care treatments for a left thigh wound for nine days after the wound was discovered for one (R1) out the three residents reviewed for wound care treatments in a total sample of three. This failure resulted in the left thigh wound increasing in size from 6.5cm x 5.5cm x 4cm to 9cm x 4cm x 4cm within seven days. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1 was admitted to the facility on [DATE]. The Wound Assessment Details Report dated 10/16/23 documents the left front thigh wound was identified on this day. It is documented as unstageable. The wound measures 6.5 cm x 5.5 cm by unknown. There is no documentation of what kind of dressing was applied to the wound. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a serious injury of unknown origin immediately within two hours to the regulatory agency for one (R1) out of three residents reviewed for reporting injury of unknown origin. Findings Include: R1 is a [AGE] year-old with the following diagnoses: functional quadriplegia and osteomyelitis of the sacral region. R1was admitted to the facility on [DATE]. A Nursing note dated 11/7/23 documents the floor nurse (V8) was informed by the wound care nurse (V4) that R1's left thigh wound was bleeding. Upon observation, R1 was awake and in no distress. Bleeding was observed to the left thigh wound. The wound care nurse applied pressure to the site. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly insert a urinary catheter and inflated the catheter balloon in the resident's (R1) urethra during the insertion for one out of three residents reviewed for catheter care in a total sample of six. This failure caused R1 to be hospitalized for a traumatic urinary catheter insertion where blood collected in the urinary catheter bag, a urinary tract infection, and urinary retention. Findings Include: R1 is a [AGE] year-old with the following diagnosis: diffuse traumatic brain injury, encounter for tracheostomy and gastrostomy, and neuromuscular dysfunction of the bladder. R1 admitted to the facility on [DATE] and discharged on 9/23/23. R1's EMR- Medication Administration note dated 9/22/23 documents a new urinary catheter was reinserted due to leakage of the old urinary catheter. 100 ML of clear urine was noted. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to follow their call light policy to ensure the call light system was available at all times and within easy accessibility for 4 residents (R109, R127, R71, R4) and the facility also failed to ensure resident call lights were responded to in a timely manner for 1 (R457) of 5 residents reviewed for call lights in a final sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to a.) ensure an air mattress used for pressure reduction was on the correct settings for 3 (R1, R53, R103) of 3 residents and b.) ensure a resident with pressure ulcers received the necessary treatment and services to promote prevention of further pressure areas and healing of pressure areas, related to low air loss mattresses for 1 (R18) resident reviewed for pressure ulcers in a sample of 30. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to convulsions, anemia and paraplegia. R1's Care Plan documents in part: R1 presents with a functional deficit in bed mobility related to generalized weakness date Initiated: 01/14/22. R1 is at risk for skin breakdown R/T (Related to) Impaired mobility: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide the appropriate equipment for residents with contractures to prevent further decrease in range of motion for 4 (R18, R103, R117, R119) of 4 residents reviewed for range of motion in a sample of 30. Findings Include: R18 was admitted was to the facility on [DATE] with diagnosis not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, chronic osteomyelitis, pressure ulcer of sacral region, stage 4, protein-calorie malnutrition, pressure ulcer of other site, gastrostomy, unstageable and osteoarthritis. R18's Care Plan document in part: R18 has an ADL (Activities of Daily living) Self Care Performance Deficit related to dementia, disease process osteoarthritis date initiated: 09/20/22. Interventions: restorative nursing as needed date initiated: 09/20/22. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure oxygen tubing and the CPAP (Continuous Positive Airway Pressure) mask were labeled and stored properly to prevent the potential for contamination for 7 (R15, R19, R33, R49, R53, R84, R124) of 7 residents reviewed for oxygen therapy in a sample of 30. Findings Include: On 01/24/23 at 11:56am R124 was observed in bed with oxygen at 2 liters/nasal cannula unlabeled with no humidity bottle in use. R124's Physician order dated 01/18/23 document in part: Oxygen at 2L Liters/Minute Via Nasal cannula; PRN (As needed) for SOB (Shortness of breath) every 8 hours as needed for SOB/desaturation. On 01/24/23 at 11:26am R33 was observed sitting on the bed with oxygen per nasal cannula in use. The oxygen tubing was observed to be undated. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure a medication error rate of less than 5% for 4 (R157, R130, R158, R151) of 5 residents in the sample reviewed for medication administration. There were 29 opportunities and 5 errors resulting in a 17.24% medication error rate.

Inspectors wroteBased on observations interviews and records review, the facility failed to follow their policy on medication labeling and storage by failing to dispose of expired medications from three of four medication carts reviewed. This deficiency has the potential to affect 46 residents receiving medications from the three carts.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (a) follow its infection control policy to prevent transmission of communicable and infectious disease (b) ensure the appropriate use of personal protective equipment (PPE) worn by staff caring for residents on droplet and contact isolation precautions; (c) post appropriate isolation precaution signage outside rooms for residents with COVID-19 virus; (d) to follow policy and procedure on glucometer cleaning for 1 resident (R157); (e) failed to properly store the insulin pen used for 1 resident (R157) on transmission-based precaution to prevent cross contamination. These failures affected 4 residents (R61,R83, R120, R157) in a total sample of 30 residents reviewed for infection control.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their dignity policy by not knocking on resident door, for one resident (R80) in sample of 30 residents reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives with timeframes and interventions to address the resident's clinical condition for 1 resident (R127) reviewed for comprehensive care plan in a sample of 30.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow wound treatments per physician orders for 2 (R209, R357) of 2 residents reviewed for skin conditions in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide colostomy care in a timely manner for one resident (R65) reviewed for colostomy care in a sample of 30 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to a.) properly position a resident while receiving enteral nutritional feeding to prevent aspiration b.) ensure a resident enteral tube feeding was disconnected and flushed after the feeding had completed to prevent the tubing from clogging and c.) ensure a tube feeding was administered as ordered for 3 (R18, R103, R358) of 3 residents reviewed for enteral nutritional - tube feedings. Findings Include: R18 was admitted to the facility on [DATE] with diagnosis not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, chronic osteomyelitis, pressure ulcer of sacral region, stage 4, protein-calorie malnutrition, pressure ulcer of other site, gastrostomy, unstageable and osteoarthritis. R18's Order Listing Report document in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 (R158) of 5 residents observed for medication administration was free of significant medications errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow food preferences for one resident (R153) reviewed for food preferences in a sample of 30 resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for sanitizing equipment. This failure has the potential to affect 100 residents receiving meals from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on securing medication carts during medication administration on 2nd and 3rd floors for 4 out 4 medication carts reviewed for security during medication administration. Findings Include: On 4/5/2022 at 7:14am, observed V4 Licensed Practical Nurse (LPN) left her medication cart unlocked while administering medication to one of her residents. Upon returning to the cart, this surveyor asked V4 what she should have done if she is walking away from the medication cart that is not in her view, and she said that she should have locked it. On 4/5/2022 at 7:35am, V3 LPN (Night Nurse Supervisor) said that V4 should have locked the medication cart. On 4/5/2022 at 7:48am, observed V5 LPN left her medication cart unlocked while medicating one of her residents. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow its infection control policy by failing to disinfect medical equipment after each resident use. The facility failed to have an adequate supply of PPE (Personal Protective equipment) accessible to staff caring for residents on droplet and contact precautions. The facility also failed to formulate isolation care plans for residents who are on droplet and contact precautions. This failure affects all seven ( R7, R14, R15, R43, R56, R116 and R234 ) residents in a sample of 29 reviewed for infection control prevention program management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy in developing baseline care plans for two residents (R95, R97) out of 11 residents reviewed for baseline care plans in the sample of 29 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement its policy on Pressure ulcer prevention and treatment by failure to follow manufacturer recommendation in using a special low air loss (LAL) mattress. The facility also failed to follow policy in wound care. The facility also failed to update care for resident who has new development of skin impairment. This deficiency affects all three (R126, R232 and R234) residents in a sample of 29 reviewed Wound Care Management.

Inspectors wroteBased on observation, interview and record review the facility failed to implement its policy on safety to prevent aspiration for a resident on enteral tube feeding. This failure affects one (R126) of three residents in a sample of 29 reviewed for Enteral tube feeding management.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy on indwelling catheter care by failure to obtain an order and indicate medical necessity of indwelling catheter in physician order sheet (POS). The facility also failed to ensure proper positioning of down flow of urine to prevent a back flow of urine into the bladder. This deficiency affects two (R15 and R97) of three residents in a sample of 29 reviewed for indwelling catheter care management.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a Nutritional Supplement was Administered for 1 of 1 resident (R95) in a timely manner, that was reviewed for Nutrition and Hydration in a sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy on respiratory care of a resident who is on a tracheostomy tube with oxygen saturations less than 90%. The facility failed to ensure emergency spare tracheostomy tube was readily accessible in the resident's room. The facility also failed to formulate a respiratory care plan for a resident with a tracheostomy. This failure affects two (R7 and R234) of three residents in a sample of 29 reviewed for respiratory care management.