Elevate Care Riverwoods

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner and as directed by a physician for 2 of 4 residents (R1, R2) reviewed for resident safety and supervision in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's urinary catheter was kept off the floor and below the level of the resident's bladder for 3 of 3 residents (R1, R3, R4) reviewed for urinary catheters in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory tests were completed as ordered. This applies to 1 of 3 residents (R1) reviewed for laboratory services in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 27 residents (R76) in the sample of 27 was evaluated by a dentist. This failure resulted in R76 developing a tooth infection and requiring antibiotic treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of mental and verbal abuse for 1 of 27 residents (R56) reviewed for abuse in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to ensure a stop date was included in the order for as needed psychotropic medications for 2 of 5 residents (R16, R51) reviewed for unnecessary medications in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of abuse was immediately reported to administration for 1 of 27 residents (R56) reviewed for abuse in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to assist a resident to obtain medical appointments in a timely manner for 1 of 27 residents (R92) reviewed for quality of care in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to implement low air loss mattresses at the correct settings for residents with pressure injuries. The facility failed to ensure a pressure prevention wheelchair cushion was in good and working order. These failures apply to 3 of 8 residents (R9, R126, R82) reviewed for pressure injuries in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 27 residents (R153) reviewed for infection control in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided incontinence care in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 falling from the bed during care and sustaining bilateral toe fractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify pressure ulcers prior to becoming advanced stages for 2 residents (R47, R97). This failure resulted in R97 developing a stage 3 pressure ulcer. The facility failed to have preventative measures in place for a resident (R8) with a stage 4 pressure ulcer, failed to implement wound treatment for 2 residents (R26, R47), failed to provide pressure ulcer prevention measures for a resident (R35), failed to accurately assess a wound for 1 resident (R97), failed to assess a reopened, advanced stage pressure ulcer for 1 resident (R26). These failures apply to 5 of 9 residents reviewed for pressure ulcers in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hairnets were worn correctly, failed to ensure staff were knowledgeable in the use of the dishwasher, and failed to ensure expired foods were destroyed. This applies to all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer snacks for 4 of 4 residents (R68,R98,R109,R130). This applies to 1 of 1 residents reviewed for HS (bedtime) snacks in the sample of 30 and 3 residents outside of the sample.

Inspectors wroteBased on interview and record review, the facility failed to offer and perform care plan conferences for 1 resident (R26) reviewed for care plans in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's heels were offloaded and failed to identify a wound to a resident's heel for 1 of 4 residents (R8) reviewed for wounds in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to check placement prior to starting feeding, failed to flush after tube feeding, and failed to ensure a resident received tube feeding as ordered for 2 of 2 residents (R43 & R125) reviewed for tube feeding in the sample of thirty.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure narcotics for discharged residents were removed from the medication cart in 1 of 6 medication carts reviewed for the medication storage task.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered per facility's policy and procedure for 2 of 5 residents (R2, R3) reviewed for medication administration in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was safely transferred, via a mechanical lift, in a manner to prevent resident injury. This failure resulted in R1 fracturing her right clavicle(collarbone) and right lower leg (tibia and fibia), after falling out of a mechanical lift, due to the cloth sling of the mechanical lift becoming unhooked from the lift. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to complete quarterly and significant change dietary assessments on residents. The facility failed to ensure dietary assessments were completed by the Registered Dietician. The facility failed to identify resident weight loss prior to the weight loss becoming significant. The facility failed to ensure weight loss treatment interventions were initiated in a timely manner, once resident weight loss was identified. These failures resulted in R37, R69, R144, R9, and R79 sustaining a significant weight loss. These failures apply to 5 of 10 (R37, R69, R144, R9, R79) residents reviewed for weight loss in the sample of 31. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a residents medication was given as prescribed and failed to ensure medication orders were transcribed correctly to avoid a significant medication error. This failure resulted in six of R9's medications being mistakenly discontinued without a physicians order. As a result of this failure R9 developed worsening psychiatric symptoms (paranoia) and was sent to the emergency room for evaluation. This applies to 1 of 7 residents (R9) reviewed for physician orders in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/1/23, when the facility discontinued R1's medications without a physician order. V1 (Administrator) was informed of the Immediate Jeopardy on 8/30/23 at 2:21 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident (R69) via wheelchair. This failure resulted in R69 sustaining a fall with injury which included a laceration to her forehead that required sutures. The facility failed to ensure a resident was safely transferred from wheelchair to bed. These failures apply to 2 of 31 residents (R69, R37) reviewed for resident safety/supervision in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch meal was a smooth pureed consistency for four of four residents (R29, R82, R6, R53) reviewed for pureed diets in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an allegation of abuse was immediately reported to the state agency. This applies to 1 of 31 residents (R4) reviewed for abuse in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an alleged allegation of abuse was investigated. This applies to 1 of 3 residents (R4) reviewed for abuse in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a treatment orders was provided to a resident with a non-pressure wound. This applies to 1 of 31 (R4) residents reviewed for quality of life in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure urinary catheter tubing was below the level of the bladder and failed to ensure urinary catheter drainage bags were placed in a manner to prevent infection for 2 of 6 residents (R56, R108) reviewed for urinary catheters in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure tube feedings orders were followed for a resident who has fed exclusively by tube feed for 1 of 2 residents (R108) in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had prescribed oxygen therapy orders and failed to ensure a resident's nasal cannula tubing was changed and labeled according to professional standards of practice for 1 of 12 residents (R96) reviewed for oxygen in the sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were supervised during medication administration for 2 of 31 residents (R54, R9) reviewed for pharmacy services in the sample of 31.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' dietary assessments were completed by qualified dietary staff for 3 of 31 residents (R37, R144, R139) reviewed for qualified dietary staff in the sample of 31.