Elevate Care Niles

Inspectors wroteBased on interview and record review, the facility failed to establish a correct indication and frequency in the use of antipsychotic medication (Seroquel); failed to obtain complete consent for use of antipsychotic medication; and failed to adequately monitor adverse reactions, evaluate effectiveness and relevance of antipsychotic medication on a resident with Alzheimer's disease. This failure resulted in R1 hanging himself with a cellphone cord and required emergent transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents (R1 and R2) who need assistance with ADLs (Activities of Daily Living) is given nail care, shaved facial hair and provided incontinence care in a timely manner. This failure affects two (R1 and R2) of three residents reviewed for ADL care program.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement wound/skin care interventions to prevent deteriorating of MASD (Moisture Associated Skin Disorder), to resident (R1) who is at high risk for skin impairment. This failure affects one (R1) of three residents reviewed for Pressure Ulcer/Wound Care Management.

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 3 of 3 (R1, R2, and R3) residents reviewed for Activities of Daily Living (ADL) care in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-dose medications are labeled and discarded accordingly for one of two medication rooms (second floor medication room) reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review the facility failed to date and label food items and beverages after preparing and storing. The facility also failed to maintain sanitizing solution at level required per manufacturer's instruction. This deficiency affects all 146 residents in the facility receiving food trays from kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R10) of three residents in the sample of 34 reviewed for ADLs (Activity of Daily Living) Program.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure splints/braces are applied to residents with contractures affecting two of seven residents (R111, R139) reviewed for range of motion.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and monitoring to prevent accidents for two of four residents (R183 and R129) reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral (tube) feeding was administered at a correct rate per physician order and enteral feeding container was labeled per policy. This deficient practice has the potential to affect 2 of 2 residents (R124, R39) reviewed for enteral feeding management in a sample of 34. Findings Include:On 11/18/2025 at 08:30 AM, R39 was observed in his room. R39's tube feeding was infusing at the rate of 55 ml/hr (milliliters/hour). On 11/18/2025, at 12:15 PM, V8 (LPN-Licensed Practical Nurse) observed with surveyor R39's tube feeding infusing at the rate of 55 ml/hr. At 12:17 PM, V8 and surveyor reviewed R39's tube feeding order. R39's physician order indicates enteral feed every shift (nutritional supplement) 1.5 @ 65 ml/hr. V8 said that R39 tube feeding rate should have been set at 65 ml/hr per physician order. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow a provider order for a STAT (immediately) x-ray to be completed for a resident after a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a delay in being transferred to the hospital for evaluation and treatment of a fractured hip, which required surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision/touching assistance for a resident when moving from a seated to standing position, per the residents plan of care and assessments, in order to prevent a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a fall causing a fractured hip that required surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to follow their call light policy and answer residents' call light in a timely manner for three (R1, R3, and R4) residents out of four residents reviewed for call lights in a total sample of four residents. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow manufacturer's instruction in using low air loss (LAL) mattress by using multiple layers of linens for residents with pressure ulcers and at high risk for skin impairment. The facility also failed to apply bilateral heel protectors as ordered by physician and care plan intervention. This deficiency affects all five ( R62, R100, R104, R112 and R208) residents in the sample of 30 reviewed for Pressure ulcer prevention management.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and supervise a resident (R154) who is identified at high risk for elopement that had eloped from the facility. The facility also failed to ensure no medications and used syringes were left at a resident's bedside. This deficiency affects all four residents (R20, R43, R53 and R154) in the sample of 30 reviewed for Residents' safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and dignity to a totally dependent and cognitively impaired resident. This deficiency affects one (R208) of three residents in the sample of 30 reviewed for Resident's rights.

Inspectors wroteBased on interview, and record review the facility failed to obtain discharge orders from the physician to transfer a resident (R154) to another facility and failed to provide a discharge summary to the continuing provider and receiving facility at the time of discharge. This deficiency affects one (R154) of one in the sample of 30 reviewed for Discharge summary.

Inspectors wroteBased on observation and record review the facility failed to provide a resident (R111) with a backup tracheostomy tube of appropriate size at the bedside for accidental extubation. This deficiency affects one (R111) of three residents in the sample of 30 reviewed for Respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its medication administration policy by failing to administer treatment medication by authorized personnel and failed not to administer medication treatment supplied for one resident to another resident. This deficiency affects one (R53) of three residents reviewed for Medication administration safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living for 2 of 4 residents (R2, R3) reviewed for activities of daily living in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staffing was sufficient to provide care for residents for 3 of 8 (R1, R2, R3) residents reviewed for staffing in the sample 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of resident by not having two staff members provide personal care for 1 of 3 residents reviewed for abuse/injuries of unknown origin in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents medications were available and administered on time for 1 of 3 residents (R1) reviewed for medications in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to provide a resident with assistance with ADLs (activities of daily living) in preparation for an outside medical appointment. This failure applied to one (R4) of three residents reviewed for assistance with ADLs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from misappropriation of property for 2 of 3 residents (R9 and R10) reviewed for misappropriation of property in the sample of 12.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the resident had a phone in good working condition to communicate to 1 of 3 residents (R3) reviewed for phone access in the sample of 16.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to consistently monitor resident's skin every shift, turn and reposition every two hours, carry out wound treatment orders as prescribed, and implement pressure relieving interventions to prevent a facility acquired pressure ulcer from recurring for one resident. This affected one of three residents (R3) reviewed for pressure sore prevention. This failure resulted in R3's sacral/right buttock stage 3 pressure ulcer re-opening and new wound treatment orders to be obtained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide incontinence care in a timely manner. This failure applied to one (R1) of one resident reviewed for incontinence care.

Inspectors wroteBased on interview and record reviews, the facility failed to include documentation in the residents medical record of assessment and monitoring of tracheotomy status and cares provided. This failure affected one (R7) of one resident reviewed for tracheotomy care and resulted in R7 being found unresponsive, with tracheotomy tube not in place and the facility was not able to identify how long the resident was without the trache tube in place; R7 expired of respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to have effective interventions in place to prevent a resident, admitted with intact skin, from developing a Stage III pressure injury while in the facility. This failure applied to one (R4) of one resident reviewed for pressure ulcers.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not identifying and implementing personalized care plan interventions on admission and not providing adequate supervision for a resident at high risk for falls; they also failed to adequately supervise or remove a safety hazard when identified, for a resident at high risk for falls. These failures applied to two of three residents (R5 and R6) reviewed for falls and resulted in R5 sustaining a head injury requiring sutures.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for notification of change in condition by not notifying a family member of the development of skin abnormalities for a resident at high risk for skin alteration. This failure applied to one of three residents (R5) reviewed for notice of change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide incontinence care in a timely manner for dependent residents and failed to ensure that staff follow facility incontinence care policy while providing care to residents. This failure affected two of two (R1, R12) residents reviewed for incontinence care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure that one residents (R313) wound was assessed properly and worsening wound was identified, and doctor was notified for one resident R313 of 3 residents reviewed for wounds in a sample of 33.

Inspectors wroteOn 7/18/23 at 12:20pm Observed R88 lying on scoop mattress. V19 LPN said that R88 is at high risk for fall and just fell recently. On 7/19/23 at 9:58am, V7 Restorative Nurse (RN) said that she does the formulation and updating fall care plan. V2 DON does the initial investigation and root cause analysis after each fall. The floor nurse will do the fall incident documentation and report the incident. Review R88's medical record with V7 RN. V7 said that R88 is admitted on [DATE] with diagnosis listed in part but not limited to history of falling, Laceration to part of head due to fall, Vascular dementia. V7 said that admission fall assessment done on 1/5/23 indicated that R88 is at high risk for fall. V7 said that R88 has several incidents of unwitnessed fall namely: 2/1/23 - Unwitnessed fall. R88 observed sitting on the floor in his room. 5/15/23- Unwitnessed fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain range of motion for four of seven residents (R47, R62, R70, R100) reviewed for range of motion in the sample of 33.

Inspectors wroteBased on observation interview, and record review the facility failed to implement appropriate infection prevention and control practices during medication administration including skin disinfection prior to administering injection to site and disinfection of medical equipment such as BP apparatus and oximeter after each resident use. This deficiency affects all six (R9, R55, R66, R87 R109 and R136) residents in the sample of 33 reviewed for infection control during medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (R43) of 3 residents reviewed for activities, was raised from the bed in the last year.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ongoing assessment, documentation, and notification of primary care physician for appropriate treatment and worsening of resident's body rashes. The facility also failed to prevent resident who is at high risk for skin impairment to develop several blisters to his bilateral lower extremities. This deficiency affects two (R37 and R463) of four residents reviewed for Skin Impairment Management and Prevention.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the physician order of resident receiving oxygen. This deficiency affects one (R52) of three residents in the sample of 33 reviewed for Respiratory care.