Elevate Care South Holland

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure; failed to document the administration of medications (controlled substance); and failed to document in a resident's medical record a fall with serious injury in a timely manner. These failures affected one resident (R1) of three residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff follow professional standards of practice of carrying out physician orders for one resident (R3) and failed to document resident assessment in medical record for five residents (R2, R3, R4, R5, R6) These failures affected five residents (R2, R3, R4, R5, R6) of six residents reviewed for nursing care, and have the potential to affect all 125 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff provide scheduled shower for residents who were dependent on staff for Activities of Daily Living (ADL) and failed to ensure that skins assessments were completed and documented as ordered. This failure affected five residents (R2-R6) of five residents reviewed for ADL care.

Inspectors wroteBased on observation interview and record review, the facility failed to provide services to promote wound healing by failing to obtain wound cultures as ordered for one (R3) of three residents reviewed for pressure ulcer.

Inspectors wroteBased on interviews and record review, the facility failed to provide individualized fall interventions for one resident (R1) out of three residents reviewed for falls. R1 was assessed as a high risk for falls upon admission, fell out of bed twice in one week, was found to be unresponsive after the second fall, code blue was called, resident was revived and sent to local hospital for further management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Weight Assessment and Interventions Policy and Unintentional Weight Loss Policy. Specifically, the facility did not report poor appetite and decreased oral intake to the physician and dietician and failed to develop interventions to prevent further weight loss. Additionally, the facility failed to ensure that one resident who was identified as at risk for malnutrition and dependent on enteral nutrition, received his enteral feeding as ordered. The facility also failed to implement dietician recommendations and to evaluate interventions to promote weight gain. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its Pain Management Policy. The facility did not assess a resident with new-onset pain, failed to document the new-onset pain, and did not ensure the resident's physician was notified or obtain an order for pain medication for one resident (R17) out of three reviewed for pain management in a sample of 44. As a result, R17 experienced psychosocial harm, enduring excruciating pain for more than 20 hours without pain medication. R17 self-reported a pain rating of 12-13 on a 1-to-10 scale.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician order and ensure the low air loss mattress was in place for a resident identified with a pressure sore. This affects one of three residents (R3) reviewed for pressure prevention interventions in place in the sample of 44. On 2/4/26 at 1:20pm R3 was observed resting in bed in supine position, V25 (Certified Nurses Assistant/CNA) was assisting R3 with his meal. R3 was observed resting on a regular mattress. V25 verified that R3 was not resting on a low air loss mattress. There was not a pump for the air mattress noted. V25 said R3 has a pressure sore to the perineal area and buttocks. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the call light was within reach for one of eight dependent resident (R129) reviewed for accommodation of needs in sample of 44. On 2/4/26 at 12:58pm R129 was observed sitting at the bedside, R129 awake able to answer yes and no questions, R129 also communicates using gestures. When asked if R129 had his call light, R129 looked left and right and said no. R129 call light was observed wrapped around the headboard. Before leaving the room R129 gestured for surveyor to turn off room light. At 1:22pm R129's call light remained wrapped around the headboard. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a Level II PASARR (preadmission screening and resident review) evaluation was completed for one resident with a diagnosis of mental disorder during the stay. This affects one of three residents (R113) reviewed for PASARR's in a sample of 44.

Inspectors wroteBased on interviews and record reviews, the facility failed to update a resident's nutrition care plan within seven days of his comprehensive assessment that noted significant weight loss in one month. This failure affected one resident (R34) out of three residents reviewed for care plan revision in a sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to follow the medication administration policy and physician orders to ensure residents receive their prescribed medication. This affects one of three residents (R13) reviewed for medication administration in a total sample size of 44. Findings Include:On 2/5/26 at 3:00pm, V15 (Family of R3) said, R13 missed his chemotherapy medication in January after she gave it to V8 (Assistant Director of Nursing/ADON). On 2/7/26 at 9:55am, V2 (Director of Nursing/DON) said, R13's medication was not given because V8 (ADON) had R13's medication on her desk which was inaccessible to the floor nurse at the time of administration. V2 said, he expects the nurse to follow doctor's orders and give medication as prescribed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication storage policy by not documenting the open date on two open bottles of tuberculin solution for two of two bottles reviewed for medication storage.

Inspectors wroteBased on record review and interviews the facility failed to provide a resident's medical record to the Power of Attorney (POA)/Healthcare Representative (HCR) in a timely manner after a request was made, for 1 (R11) of 1 resident reviewed for medical records request.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing revision and updated the resident individualized care plan according to the resident's condition and treatments. This deficiency affects two (R5 and R6) of three residents reviewed for Care plan revision.

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 (R5) of three residents reviewed for Fall prevention program.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a feeding tube was administered as ordered for one resident (R8) reviewed for tube feedings.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's order for oxygen administration affecting one (R6) of three residents reviewed for oxygen administration.

Inspectors wroteBased on interview and record review the facility failed to ensure that medications were administered as ordered by a physician, for two (R5 and R8) of two residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during wound care observation and oxygen administration. This deficiency affects one (R6) of three residents reviewed for Infection control prevention program.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to follow the LALM (Low Air Loss Mattress) manufacturer guidelines, failed to implement care plan interventions, failed to ensure that a LALM (Low Air Loss Mattress) in use was functioning properly, failed to ensure that the LALM was on the correct settings, failed to transcribe wound care orders in the POS (Physician Order Sheets) and TAR (Treatment Administration Record), and/or failed to follow physician orders for three of four residents (R2, R3, R4) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the ice scoop is stored outside of the ice cooler box for the 2nd floor. This failure has the potential to affect all 45 residents currently residing on the 2nd floor.

Inspectors wroteBased on interviews and record review, the facility failed to protect a resident's (R1) right to be free from physical abuse from an employee for one (R1) of four residents reviewed for abuse in a sample of four. This failure resulted in R1, who is severely cognitively impaired, being physically assaulted by an employee and experiencing pain. R1, as a reasonable person would not expect to be harmed in their own home or health care facility, causing them to feel fear, anxiety, and anger.

Inspectors wroteBased on interview and record review, the facility failed to transfer one resident to the hospital after a new onset of pain and abnormal x-ray results for an acute fracture. This affected one of three residents (R2) reviewed for radiology results, and nursing assessments. This failure resulted in R2 having increased pain and a 5 day delay in sending R2 to the local hospital for treatment. Findings Include: R2 has diagnoses of Osteoarthritis, Syncope Episode, Radiculopathy, Raynaud's syndrome and a fall with Right hip fracture. Physiatry Progress noted dated 2/7/25 documents: Service date: 2/6/2025 documents: The patient (R2) was seen and examined today. Received R2 today up in the bed with complaints of pain to her right hip. Tenderness to touch. This is an old right hip surgery. R2 reporting new-onset pain. R2 has limited range of motion to that right leg with pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe enviroment while providing direct incontinence care. This affected one of three residents (R8) reviewed for saftey while providing care. This resulted in R8 losing his balance and falling to the floor and sustaining a left hip fracture requiring surgical intervention. Findings Include: R8 has diagnoses of Alzheimer's Disease, Syncope And Collapse, Hypertension, Dementia without Behavioral Disturbance and Anxiety, Lack Of Coordination, Difficulty In Walking, Weakness and Cognitive Communication Deficit. Minimal data set section C (cognitive pattern) dated 1/16/25 documents a score of three which indicated severe cognitive impaired. Section GG (functional abilities) documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to have pain medication available Hydrocodone-acetaminophen PRN (as necessary). This affected one of three residents (R6) reviewed for pain. This resulted in R6 being without pain medication and stated she was in extreme pain for about 1 day. R6 was status post laminectomy. Findings Include: R6 has a diagnosis of Spinal stenosis, lumber region with neurogenic claudication, lumbago with left side sciatica and Osteoarthritis. Brief interview for mental status dated 1/21/25 documents a score of 15 which indicates cognitively intact. Nursing note dated 1/16/25 documents: resident (R6) was admitted post lumber laminectomy (surgery to ease pressure on the spinal cord and nerves of the lower spine). [...]

Inspectors wroteBased on interview and record review, the facility signed/forged a residents family members name without permission to the admission contract without permission. This affected one of three residents (R1) reviewed medical records. Findings Include: On 2/25/25 at 10:28am, V17 (family) said, V1 forged her name on R1's admission package to take all of her assets. On 2/26/25 at 4:23pm, V7 (admission coordinator) said, he electronically signed R1's family name on the admission contract on the tablet to meet his deadline from corporate. V7 said, he realized it was wrong so he got rid of his signed package. V7 said, a copy was automatically emailed to V17. Police report dated 2/24/25 documents: V17 (R1's emergency contact #1) she is a representative for R1. V17 states she received an admission packet through email from the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy in ensuring that a urinary catheter drainage bag was placed in a privacy bag for one (R106) of three residents reviewed for dignity in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral (tube) feeding was administered according to physician order. This deficient practice has the potential to affect 1 of 2 residents (R37) reviewed for enteral management and administration in a sample of 24. Findings Include: During facility observation round, on 12/10/2024 at 11:25 AM, R37's tube feeding was hanging but was not connected or turned on as ordered. V9 (Licensed Practical Nurse/LPN) stated the physician order states for the tube feeding to be on at 9AM and feeding should have been turned on. On 12/11/2024 at 10:56 AM, V2 (Director of Nursing/DON) stated tube feeding should have been turned on according to physician's order. Nurses are expected to follow and carry out physician's order. admission Record: Diagnosis Information Encounter for Attention to Gastrostomy Order Summary: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the oxygen humidifier bottle was labeled with appropriate date. This deficient practice has the potential to affect 1 of 3 residents (R7) reviewed for Oxygen administration and management in a sample of 24. Findings Include: During facility round observation on 12/10/2024 at 11:40 AM, R7 was using oxygen via nasal cannula with the portable concentrator and undated attached humidifier bottle. V14 (Licensed Practical Nurse/LPN) stated humidifier bottle should be labeled with the date so that staff will know when to change it. V14 said he will change the bottle and put the date on it. On 12/11/2024 at 11:00 AM, V2 (Director of Nursing/DON) stated oxygen humidifier bottle should be labeled with the date and changed once a week. admission Record: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices, such as the use of personal protective equipment (PPE), was performed during blood glucose monitoring procedure. This deficient practice has the potential to affect 1 of 10 residents (R37) reviewed for use of PPE in a sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results indicating high amount of bacteria (greater than 100,000 pseudomonas aeruginosa) for one resident (R2) who had a stage three sacral pressure ulcer. This affected one of three (R2) residents reviewed for notification of an abnormal lab result. This failure resulted in R1 not receiving any antibiotic treatments and being hospitalized two weeks later with a diagnosis of sacral osteomyelitis.

Inspectors wroteBased on interview and record review, the facility failed to monitor and supervise to prevent a resident (R1) from leaving the facility unauthorized who assessed to have supervised pass privileges. This affected one of three residents (R1) reviewed for supervision. This failure resulted in the resident exiting the facility unauthorized on 10/17/24, at 4:45pm via the front lobby entrance without staff intervention and being gone approximately fourteen hours without staff knowledge of whereabouts. Findings Include: [...]

Inspectors wroteDeficiencies at this level require more than one Deficient Practice Statement. A. Based on interview and record review, the facility failed to follow their practice and provide a staff escort to an appointment for a resident R1 diagnosed with dementia, BIMS (Brief Interview for Mental Status) score of 5, identified not capable of unsupervised outside pass privileges. R1 was dropped off by transportation company on 5/8/24 at approximately 2:00pm, unknown drop off point. R1 was later found by family in streets trying to self-propel over a curb ramp approximately 3:30pm. This affects 1 of 1 resident (R1) reviewed for supervision. The Immediate Jeopardy which began on 05/08/2024 when R1 was dropped off at around 2:00pm at an outpatient appointment alone, without a staff escort, and later found in the community approximately 1.5 hours later by his daughter in the streets. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform dressing changes and daily assessments of a wound as ordered for two days, and failed to address a foul odor in the sacral wound for six days. This affected one of three residents (R6) reviewed for pressure sore prevention and treatment. This failure resulted in an abscess/infection forming behind the sacral wound that needed to be surgically drained while hospitalized , and the sacral wound developing a foul odor which was not identified at the facility. Findings Include: R6 is an [AGE] year old with the following diagnosis: urinary tract infection, peripheral vascular disease, hemiplegia of the left and right side following a cerebral infarction, and chronic ischemic heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an effective plan of care to include monitoring to prevent a dementia resident assessed to be at high risk for falls from falling, and failed to ensure facility staff provided safe bed mobility while providing direct resident care. This affected two of three residents (R1, R2) reviewed for fall prevention and safety. This failure resulted in R1 suffering a right sided pelvic fracture, and resulted in R2 sustaining a laceration to the head that needed to be repaired with Dermabond at the hospital. Findings Include: 1. R1 is an [AGE] year old with the following diagnosis: dementia, encephalopathy, weakness, lack of coordination, heart failure, and chronic kidney disease stage 3. R3 is an [AGE] year old with the following diagnosis: type 2 diabetes and chronic obstructive pulmonary disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a nurse on 7am-3pm shift on February 11, 2024, on 2nd floor north side unit to administer medications to the residents. This deficiency affects all 24 residents on the 2nd floor north side unit in the sample of 26 reviewed for sufficient staff.

Inspectors wroteBased on interview and record review, the facility failed to administer scheduled medications to residents on 2/11/24 for 7-3 shift. This deficiency affects all six (R10, R46, R58, R76, R80 and R110) residents in the sample of 26 reviewed for Medication Administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control prevention and control practice during medication administration and incontinence care, by failing to disinfect digital blood pressure monitoring equipment after each resident usage, and failing to perform hand hygiene during incontinence care. This deficiency affects four (R10, R108, R118 and R181) residents in the sample of 26 reviewed for Infection Control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer recommendation regarding using of low air loss (LAL) mattress in avoiding multilayer linens over the mattress to resident who has a pressure ulcer. This deficiency affects one (R71) of three residents reviewed for pressure ulcer prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate account of controlled drug in locked medication cart. This deficiency affects one (1st floor medication cart) of three medication carts reviewed for Medication storage of Controlled substance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented to include the use of wrist bands to identify resident at risk for falling. This affected four of five residents (R2- R5) reviewed for fall risk, and fall risk identification. Findings Includes: 1. R2's diagnosis include but are not limited to Hemiplegia and Hemiparesis following Cerebral Vascular Infarction, Fall, Contracture of Muscle Multiple Sites Including Left knee, Cognitive Communication Deficit, Weakness, and Paralytic Gait. Incident Report, dated 5/27/23 at 8:24PM, indicates R2 seen lying on the floor. R2 verbalized she was trying to turn on her other while in bed. Care Plan for R2's interventions include bedside mat initiated on 6/1/23. Incident Report, dated 07/21/23 at 8:16PM, indicates R2 observed on the floor. R2 said she fell from the bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Emergency Care policy and procedure by not immediately calling 911 for residents identified to be in need of emergency medical assistance. This failure applied to two (R9, R12) of two residents reviewed for emergency services, and resulted in R9 noted to be experiencing symptoms of a stroke for over an hour before being transferred to the hospital; R12 experienced acute respiratory distress for over 40 minutes before 911 was called. The Immediate Jeopardy began on 7/4/23 when the facility failed to immediately call 911 for R9, who was experiencing symptoms of a stroke. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 11:07AM. [...]

Inspectors wrote3. R3 is an [AGE] year-old female with a diagnoses history of Atrial Fibrillation, Adult Failure to Thrive, Dementia without Behavioral Disturbance, Weakness, Lack of Coordination, and Abnormalities of Gait and Mobility, who was admitted to the facility 10/01/2022. R3's current care plan, initiated 10/18/2022, documents the resident has a behavior problem; has dementia---and has behavior of reporting falls, however patient is not able to get up by herself with interventions including Anticipate and meet the resident's needs; R3's current care plan, initiated 12/01/2022, documents she is at risk for falls. R3's Quarterly Minimum Data Set Assessment, dated 04/02/2023, documents she requires extensive one person assistance for transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to assist a resident (R12) with a resident-initiated transfer; and failed to respond to concerns brought up by family members about nurse staff in regard to care provided to their cognitively impaired family member (R6). These failures applied to two (R6 and R12) of two residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to keep residents from being abused by other residents as a result of resident-to-resident altercations. These failures applied to four (R4, R5, R13, and R14) of four residents reviewed for abuse.