Elevate Care Palos Heights

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by not protecting one resident (R12) from theft of personal property. This failure resulted in R12 having her wallet stolen, unauthorize purchases on her credit cards by V29 (CNA/certified nursing assistant), and feeling unsafe at the facility for 1 of 3 residents (R12) reviewed for allegations of misappropriations of property.

Inspectors wroteBased on interview and record review, the facility failed to follow their post fall management policy by moving/picking up one resident ( R5 ) from the floor, who complained of head and neck pain following a fall before a nursing assessment and evaluation was performed for one of three residents reviewed for falls. Findings Include: R5 was admitted to the facility on [DATE] with a diagnosis of quadriplegia, amyotrophic lateral sclerosis (ALS) and dysphagia. R5's progress note dated 5/20/26 documents: At about 4:20 pm, this writer (V9) was informed by a CNA that R5 had a fall. Evening Supervisor immediately notified. This writer together with the Supervisor went to the room to check, upon entering the room, R5 was already back up on her wheelchair. V35 (R5's family) was at bedside and stated that R5 fell backwards on her high back wheelchair. R5 was being prepared to be put back in bed. [...]

Inspectors wroteBased on interview and Record review the facility failed to develop individualized ADLs (Activity of Daily Living) plan of care for Eight of Eight residents (R5, R6, R7, R8, R9, R10, R13, and R15) and failed to educate residents and family on anticoagulant medication for two residents (R8 and R9) in the sample reviewed for ADLs. This failure affected R5, R6, R7, R8, R9, R10, R13, and R15 who were dependent on staff for ADLs assistance and had the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure staff obtained the resident permission prior to checking for incontinence, and inappropriately touched a resident in her vaginal area. This affected one of three residents reviewed for abuse. This failure resulted under the reasonable person concept, in R1 expressing she felt angry, violated, she felt like V1 took something from her emotionally, she wanted to fight. R1 BIMs completed on 9/15/25 denotes in-part R1 was able to report correct year, R1 was able to report correct day of the week, R1 was able to repeat three words after first attempt. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy to report an allegation of abuse within two hours of receiving an allegation for one of three resident (R1) reviewed for abuse reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a working kitchen exhaust fan and failed to replace the broken tiles. This applies to all 92 residents consuming food from dietary services. On 7/10/25 at 11:25 AM, observed kitchen with broken floor tiles (ceramic) throughout the kitchen. Observed that the exhaust fan above the stove is not working and the temperature around the stove area was unusually hot. On 7/10/25 at 11:32 AM, V6 (Dietary Aide) stated, I have been working in this kitchen for one and a half years. The kitchen floor tiles have been broken since I started here. On 7/10/25 at 11:35 AM, V7 (Cook) stated, Our exhaust fan was not working yesterday either. Air is working with two window units. The kitchen floor tiles were broken when I started here five years ago. [...]

Inspectors wroteBased on the interview and record review, the facility failed to establish and maintain a system for recording and releasing resident funds based on generally accepted accounting principles. This applies to 1 of 3 residents (R1) reviewed for the resident fund in a sample of 8. R1 was an [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 7/10/25 at 9:10 AM, V10 (R1's granddaughter) stated, After my grandpa (R1) passed away on 6/7/25, my mom received a phone call from the nurse that R1 had $200 cash and a cashier's check of $400 to be picked up. When my mom and my grandma (who passed away one week after my grandpa) stopped by to collect money, V1 (administrator) told them that the money had already been released. But we never received that money. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a clean, comfortable, home-like interior. This applies to 5 of 8 residents (R4, R5, R6, R7, and R8) reviewed for the sanitary, comfortable, home-like environment. On 7/10/25 at 10:20 AM, observed 300 hallways with urine and feces smell, and a common shower room with a dirty/foul smell. On 7/10/25 at 10:22 AM, V12 (Housekeeping) stated that he doesn't know where the foul smell is coming from, and he is on his way to clean the common shower room. 1. R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 3 residents (R4, R5, and R6) reviewed for activities of daily living (ADL) care in a sample of 7. 1. R4 is a [AGE] year-old female having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R4 is dependent on toileting hygiene. On 7/10/25 at 10:28 AM, observed R4 in her bed with an intense urine and feces smell. On 7/10/25 at 10:30 AM, V3 (Certified Nursing Assistant/CNA) checked on R4 for incontinence and was found with urine and feces-soaked brief with urine and feces leaked onto pads and then to linen with brownish discolored linen. A review of R4's bowel and bladder care plan document with interventions including cleaning the peri-area with each incontinent episode. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light is within reach affecting 2 of 2 (R2, R34) residents reviewed for Accommodation of Needs in a sample of 20 Findings Include: On 1/21/2025 at 11:20 AM, R2 in bed, call light not within reached. V6 (Certified Nursing Assistant/CNA) said R2 uses a custom call light that V6 was not able to find within R2's reach. On 1/23/2025 at 10:45 AM, V2 (Director of Nursing/DON) said call light should be within reach of resident. admission Record: Diagnosis Information Cerebral Palsy, Unspecified Contracture, Unspecified Joint Care Plan: Encourage R2 to use custom call light r/t contractures of all extremities for staff assistance. Policy and Procedure: Call Light, Revisions: 2-2-18 Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of respiratory equipment. This deficiency affects two (R6, R23) of four residents in the sample of 20 reviewed for Infection control.

Inspectors wroteBased on interview and record review the facility failed to ensure a proper blood draw from a resident with limb precautions. This failure affected 1 resident (R1) of 3 reviewed for laboratory services.

Inspectors wroteBased on interview and record review, the facility failed to prevent one resident (R1) from mental abuse caused by a staff member and failed to ensure the staff member had limited access to R1. This failure applied to one (R1) of three residents reviewed for abuse and resulted in R1 feeling on guard, untrusting and unsafe while living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from misappropriation of resident property. This failure applied to one (R1) of three residents reviewed for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of property for a resident and failed to timely report an allegation of physical abuse for one resident to the Illinois Department of Public Health (IDPH). These failures applied to two (R1, R3) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that an allegation of misappropriation of property was thoroughly investigated for a resident. This failure applied to one (R1) of three residents reviewed for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to maintain a record of controlled substances proof of use accounting for each dose of narcotic medications given and disposed. This failure affected 15 of 15 residents (R6-R21) who were reviewed for disposition of controlled drugs.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident with a mechanic lift. This failure resulted in staff transferring R2 to bed from wheelchair via mechanical lift, during the transfer R2's left foot bumped the footboard which resulted in fracture to the left distal tibia. This failure affected 1 resident (R2) in a sample of 5 reviewed for accidents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect a cognitively impaired resident from physical and emotional abuse by a staff member who forcefully pushed the resident in her wheelchair and shouted at the resident out of frustration which caused the resident to be fearful of the staff member, emotionally distraught and intimidated; and facility failed to follow their policy on abuse prevention. This failure affected one (R81) of 5 residents reviewed for abuse from a sample of 37 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on hand washing during food preparation and failed to properly wear hair nets during food preparation in the kitchen. This failure has the potential to affect all 97 residents who receive oral meals from the facility's kitchen. On 03/06/23 at 10:30 AM, during the kitchen observation, V17 [NAME] noted with a large amount of hair outside the back of her hair net while preparing food over the stove. V17 was inquired of her hair net. V17 [NAME] stated, Oh I thought it was all in. V17 [NAME] attempted to fix her hairnet by pushing the hair up into the net while standing at the stove and was instructed by V15 Dietary Manager to go over to the hand washing sink area away from the food. On 03/07/23 at 10:47 AM, V17 [NAME] observed touching the garbage can lid during preparation of pureed food. [...]

Inspectors wroteBased on observation, interview and record review facility failed to follow isolation procedures and usage of PPE's (Personal Protective Equipment) for Enhanced Barrier Precautions for 5 (R12, R30, R37, R43, R58) residents; failed to post signage alerting visitors of active Covid case in the facility. This failure has a potential to affect all 98 residents currently residing in the facility.

Inspectors wroteBased on interview and record review facility failed to inform residents, their representative, and families of confirmed Covid-19 case in the facility. This failure has a potential to affect all 98 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent an accidental hazard for 1 (R69) out of resident reviewed for accident hazards in the sample of 37.