Elevate Care Des Plaines

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free from physical and psychosocial harm. This failure caused right ear and abdominal bruises and mental anguish for 1 of 3 residents reviewed (R3) for abuse in a sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall preventive measures for a resident who is a high fall risk. This deficiency affects one (R121) of six residents in a sample of 35 reviewed for Falls.

Inspectors wroteBased on interview, observation, and record reviews, the facility failed to provide timely assistance with toileting/incontinent care and personal hygiene for three (R4, R5, R6) of four residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Respiratory Care Equipment and Supplies policy by failing to change ventilator circuits and filters. This applies to 1 of 3 residents (R1) reviewed for ventilator (Vent)/Tracheostomy (trach) care in a sample of 3.

Inspectors wroteBased on interview and record review, the facility experienced a power failure related to an area wide power outage. The facility's backup generator failed to provide back up power for the facility as it is designed to do during a power outage. The facility failed to ensure the safety of all residents dependent on life-sustaining equipment related to inability to provide electricity to life sustaining devices during the power failure. The facility failed to document the generator was in working order by completed weekly testing and monthly testing under load to ensure the backup generators availability in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents dependent on life-sustaining medical equipment received the specialized respiratory care and continuous clinical monitoring essential to prevent life-threatening complications. during a total facility power loss. These failures affect all residents (R1-R15) who are ventilator dependent.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident remained free from staff to resident abuse for one of three residents (R1) reviewed for abuse. This failure resulted in R1 sustaining physical injuries and R1 being transported to the emergency department for treatment, ultimately resulting in R1's request discharge against medical advice due to fear and dissatisfaction with the facility. R1 is a [AGE] year-old with diagnoses including heart failure, epilepsy, hypertension, hyperlipidemia and anxiety disorder. On 7/18/25 at 1:50 PM, V1 (Administrator) said she was the abuse prohibition coordinator and was present in the building due to flooding in the basement that evening she was trying to address when V4 nurse had an altercation with the resident R1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders by failing to monitor and apply a resident's negative pressure wound therapy and dressing for a resident with necrotizing fasciitis to the right foot. These failures affect one of three residents reviewed for wound care. This failure resulted in R2 not receiving wound treatment for 5 hours, calling 911, and being transported to local emergency room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for hydration and tube feeding tube care by not ensuring that a resident received the recommended amount of fluids for a resident who is dependent on tube feeding for nutrition. This failure applied to one (R1) of four residents reviewed for hydration and resulted in R1 being hospitalized with diagnoses including dehydration, high blood sodium, and hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for housekeeping by not ensuring the rooms and medical equipment of residents who are totally dependent on staff for care and assistance with activities of daily living, were consistently and adequately cleaned and sanitized. This failure applies to four of four residents (R1, R2, R3, R4) reviewed for environment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for feeding tube care by not following physician orders of daily cleansing and dressing of feeding tube site for residents dependent on enteral nutrition. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a urine specimen from a catheter in a timely manner, document indwelling catheter output, ensure catheter care was provided and identify/respond to signs and symptoms of a UTI (Urinary Tract Infection) in a timely manner for 2 of 3 residents (R1, R3) reviewed for indwelling catheters in the sample of 3. These failures resulted in R1 requiring emergency treatment and hospitalization for a severe UTI with sepsis.

Inspectors wroteBased on observations, interviews and records reviews the facility failed to provide a recliner wheelchair to a dependent resident. This failure affected one (R12) resident out of three residents reviewed for resident rights who expressed a desire to get out of bed and interact with the environment. Findings Includes: R12 is [AGE] years old admitted to the facility 09/08/23 with diagnoses including but not limited to multiple sclerosis, Sacral ulcer, Chronic anemia, and protein energy undernutrition. MDS (minimum data set) dated 06/17/2024 reads R12 uses a wheelchair for mobility. On 08/20/24 at 10:30AM during facility rounds R12 observed to be in bed and said, I want to get out of bed, but I don't have a wheelchair. I don't remember when the last time was, I got up. I asked the nursing assistants, but I was told I do not have a chair to get up in. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise one high risk for falls resident (R1) in a sample of 3 residents. This failure resulted in R1 falling out of an unlocked wheelchair while sitting in an unsupervised dining room. R1 sustained bruising to the left side of face and a cut above her left eye which, required hospital evaluation and 4 sutures above left eye.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow Physician Order for transmission-based precautions for 1 resident (R8) and failed to perform hand hygiene to prevent the spread of infectious microorganisms.

Inspectors wroteBased on interview and record review, the facility failed to supervise a high risk for falls resident (R2) in a sample of 5 residents. This failure resulted in R2 sitting in a wheelchair at the nurse's station, falling asleep and leaning forward and falling out of his wheelchair to the ground face down. R2 sustained small laceration to bridge of nose, required hospital evaluation and required two sutures to the nose.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's safety when providing care to prevent a fall for 1 of 3 residents (R3) reviewed for safety in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter bag was kept from resting on the floor and failed to secure the catheter tubing for 1 of 3 residents (R2) reviewed for catheters in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions to prevent the decline in range of motion. This affected one of three residents (R1) reviewed for a decline in functional abilities. This failure resulted in R1 developing a contracture of right hand and is unable to extend fingers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective preventive measures according to a resident's plan of care. The facility failed to ensure a pressure relief mattress was operated correctly. This affected one of three residents (R2) reviewed for pressure sore prevention interventions.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its Accident/Incidents Reporting policy by not completing an incident report, failing to document in the progress notes, failing to assess and monitor for any changes of condition, and failing to notify the physician and family immediately after an incident. The facility also failed to follow its Fall Prevention and Management policy by not implementing fall interventions and failing to update fall care plan after a fall for two (R1, R2) of three residents reviewed for falls. These failures caused a delay in treatment and hospitalization of R1 who sustained a left femoral neck fracture that required surgery.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from verbal and physical abuse when a CNA (Certified Nurse Assistant) was witnessed forcibly grabbing the resident's legs, threw resident's legs in bed which led to resident forcibly landing in bed and the CNA used inappropriate language directed towards resident. This affected one of three residents (R1) reviewed for abuse. This failure resulted in R1 complaining of mild shoulder pain.

Inspectors wroteBased on interview and record review the facility failed to follow the fall prevention policy to develop, implement, reevaluate the effectiveness of interventions to prevent or reduce the risk of falling for a resident with dementia, poor safety awareness, and high risk for falls. This failure affected one of three residents (R1) reviewed for fall prevention intervention. These failures resulted in R1 being involved in a fall incident causing pain to the left hip area. R1 was sent to the local hospital and evaluated and treated for a displaced left femur fracture.

Inspectors wroteBased on interview and record review the facility failed to provide pain management after a fall for a dementia resident observed by the resident's family to have facial grimacing and acting out of character and complaining to staff of left hip pain during dressing. This affected one of three residents (R1) reviewed for pain management. This failure resulted in the staff being notified that R1 was in pain by a family member post fall and R1 not receiving any pain medication. R1 was transferred to the local hospital where R1 was diagnosed and treated with a displaced left femur fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement preventative measures appropriately by not following the recommended pressure settings for an alternating pressure air mattress. This deficient practice affects 4 residents (R34, R48, R54 and R62) of 4 residents reviewed for skin alterations in a total sample of 24 residents. Findings Include: 1. On 8/22/23 at 10:30 AM, R34 was in bed on a low air loss (LAL) mattress set on 400 lbs. On 8/22/23 at 10:35 AM showed V10 (Assistant Director of Nursing) the setting of the low air loss mattress of R34 and V10 said that the setting should be close to the resident's weight. I will check the weight and readjust the setting. V10 reported to the surveyor that the weight of R34 is 170 lbs. (pounds). R34's care plan documents: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to do an accurate count of controlled medications by failing to complete the controlled drug receipt/record/disposition form upon receipt of the medications for two of four medication carts affecting five residents (R29, R59, R82, R168, R172) reviewed for controlled medication reconciliation in a sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat the residents with respect and dignity for one of four residents (R42) reviewed for resident's rights in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep an indwelling catheter collection bag off the floor for one resident (R6) of three residents reviewed for indwelling catheters in the sample of 24. This failure could result in infection.

Inspectors wroteBased on observation, interview and record review the facility failed to have the State inspection survey results available and accessible to the residents. This deficiency affects all five (R4, R8, R53, R90 and R92) residents reviewed for Resident right to Survey results in a sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe refrigerator temperatures and failed to monitor and record the temperatures daily. This deficiency affects all 4 medication refrigerators in the medication rooms reviewed for Medication safety storage.

Inspectors wroteBased on record review and interview, the facility failed to update a care plan for four of six resident's R20, R25, R31 and R41 reviewed for falls in a sample of 31 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the controlled substance policy by failing to account for the usage, disposition and reconciliation of controlled medication. This deficiency affects all 7 residents (R8, R14, R36, R39, R65, R70 and R119) in the sample of 31 reviewed for Medication storage for controlled drugs. The facility also failed to follow medication administration policy by failing to notify physician and document reason of not giving the medication in a timely manner. This deficiency affects one (R45) of 14 residents reviewed for medication administration in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate infection prevention and control practices during medication administration including disinfecting of medical equipment (wrist digital blood pressure manometer and medication plastic tray) after each resident use and failed to change gloves and perform hand hygiene after each procedure. The facility failed to maintain droplet and contact precaution to a newly admitted resident who is not fully vaccinated. The facility also failed to follow transmission-based precaution protocol. This deficiency affects all 7 (R26, R45, R62, R95, R220, R221 and R373) in the sample of 31 reviewed for Infection control and prevention.

Inspectors wroteBased on observation, interview and record review, the facility failed to administered medication as per physician orders in accordance with professional standards of clinical practice for one (R52) of seven residents in a sample of 31 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform nail care on one resident (R72) of seven residents reviewed for grooming and hygiene in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to implement care plan interventions to apply finger flexion glove splint to prevent reduction in Range of Motion (ROM) to resident who is at risk for developing contractures due to functional limitation of hand. This deficiency affects one (R37) of three residents in the sample of 31 reviewed for limited ROM.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 2 of 9 resident's (R31 and R62) reviewed for falls in a sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to stabilize the indwelling urinary catheter for one resident (R72) of five residents reviewed for catheters in the sample of 31.