Elevate Care Northbrook

Inspectors wroteBased on interviews and record reviews, the facility failed to follow professional standard of care by not timely reporting a fall accident in the facility. This deficient practice affects one resident (R5) of three residents reviewed for fall accident. During transfer, R5 legs buckled, resulting a sudden loss of weight bearing ability, staff provided support and assisted R5 to the floor to prevent a fall. Staff did not report the unusual event to the nurse during this transfer. This past noncompliance occurred on 6/2/26 to 6/9/26. Findings Include:R5 is a [AGE] year-old female resident with diagnoses of but not limited to: Right Hip Unilateral Primary Osteoarthritis, Hereditary and Idiopathic Neuropathies, and Osteoarthritis. Facility Reported Incident submitted to IDPH (Illinois Department of Public Health) dated 6/5/26, reads in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with its Abuse and Retaliation Policy and Prevention Program by failing to protect a resident from staff abuse. This failure resulted in severe pain for 1 of 3 residents (R1) reviewed for abuse in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Fall Prevention Program by failing to implement appropriate interventions to ensure the safety of fall-risk residents for 1 of 3 residents (R1) reviewed for falls. This failure has resulted in a fall with a right distal femur fracture. The facility also failed to follow its elopement policy by failing to monitor and prevent the departure of an elopement-risk resident for 1 of 3 residents (R7) reviewed for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Activities of Daily Living (ADL) care policy by failing to provide nail care to dependent residents. This applies to 1 of 3 residents reviewed (R3) for ADL care in a sample of 9.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect a resident's right to be free from physical abuse from another resident for 1 (R1) of four residents reviewed for abuse in a sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy for Abuse prevention program. This deficiency affects all four (R2, R3, R4 and R5) residents reviewed for Abuse prevention program.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and failed to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision. As a result, R1 was allowed to eat independently, experienced a choking incident, and subsequently died in route to the hospital for emergency care. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 08/12/25 when R1 had a choking incident during mealtime while being watched by V6 (Certified Nurse, Assistant) and subsequently died during transport to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and by failing to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision and resulted in R1 experiencing a choking episode and subsequently died in route to the hospital for emergency care. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage a resident with an insulin overdose in accordance with the standards of care for 1 of 4 residents (R1) reviewed for quality of care in the sample of 4. This failure resulted in a delayed transfer to the hospital, R1's wife summoning EMS (emergency medical services) and R1 being admitted to the ICU (intensive care unit) with an insulin overdose and hypoglycemia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their medication storage policy by not ensuring an insulin vial was properly labeled and stored in accordance with accepted professional practice. This failure affected 6 residents with orders for Lispro (Human) insulin (R97, R105, R124, R146, R187, R193) of 6 residents reviewed for medication label and storage.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer medications as ordered for 1 (R93) of 5 residents reviewed during medication administration in the sample of 48. There were 27 opportunities with two errors resulting in a 7.41% error rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's hospital bed was in good working order and in condition to be used safely. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall from bed that resulted in R3 sustaining a right arm (humeral) fracture. The surveyor confirmed by observation, interview, and record review that the deficient practice was corrected on 4/17/24, prior to the start of this survey, and was therefore Past Noncompliance.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its own policy by not providing the services of an onsite beautician, this failure affected four (R4, R5, R6, and R7) of four residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are personally seen by their physician for an initial comprehensive visit upon admission and at least once every 60 days while in the facility. This failure applied to four of four (R1, R4, R5, R6) residents reviewed for physician services.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for serving food under sanitary conditions by not properly wearing hair restraints, not practicing hand hygiene when necessary, not ensuring sanitizer solution was replaced when needed, not ensuring kitchen appliances were properly cleaned and stored, not ensuring the ice machine was thoroughly clean when in use, and not recording final cook temperatures. This failure has the potential to affect all 210 residents in the facility.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to follow their policy and procedure for catheter use by not ensuring a urology evaluation for urinary catheter removal was scheduled for a resident with a history of urinary tract infections. This failure applies to one of two residents (R199) reviewed for catheter and urinary tract infection.