Elevate Care Waukegan

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure linens and personal clothing were laundered and available to residents in a timely manner. This applies to 4 of 4 residents (R2-R5) reviewed for homelike environment in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility left R1 eating alone in the bedroom with a small plastic spoon to eat providing no supervision, cuing, or touch assist for 1 of 13 residents (R1) reviewed for Activities of Daily Living in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to monitor R1's anticoagulant blood levels, resulting in R1 being hospitalized for 1 of 13 residents (R1) reviewed for medication in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure plastic insulated plate bases were air dried prior to stacking and storing. This has the potential to affect all residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms were clean, and failed to provide residents with linen for bathing for 5 of 34 residents (R11, R41, R66, R124, R151) reviewed for clean, comfortable homelike in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that require extensive assistance received showers and personal hygiene care. This applies to 4 of 34 residents (R170, R160, R3, R11 ) reviewed for activities of daily living in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure puree green beans and puree beef stew were served at an appetizing temperature. This affects 4 of 4 residents (R30, R31, R37, R164) reviewed for puree diets in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a resident's care plan interventions for communication for 1 of 34 residents (R44) reviewed for accommodation of needs in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with an Advanced Directive of Do Not Resuscitate (DNR) had a physician order for DNR for 1 of 34 residents (R4) reviewed for Advanced Directives in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a resident reported grievance in a timely manner for 1 of 34 residents (R11) reviewed for grievances in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to document medical symptoms and ensure non-pharmacological interventions were implemented prior to starting a resident on Seroquel (anti-psychotic medication) for 1 of 5 residents (R17) reviewed for chemical restraints in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin and an allegation of abuse for 2 of 34 residents (R31, R133) reviewed for abuse in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident for a Preadmission Screening and Resident Review (PASARR) Level II evaluation after a new diagnosis of psychosis for 1 of 5 residents (R17) reviewed for PASARR in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with dysphagia was supervised during meals. This applies to 1 of 34 residents (R141) reviewed for safety in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter was secured to prevent pain and/or injury for 1 of 5 residents (R1) reviewed for urinary catheters in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements for a resident at risk for weight loss. This applies to 1 of 6 residents (R141) reviewed for weight loss in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights for a resident with a gastrostomy tube for 1 of 7 residents (R191) reviewed for gastrostomy tubes in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's oxygen was administered according to physician orders for 1 of 9 residents (R162) reviewed for oxygen in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to discontinue an antibiotic as ordered for 1 of 34 residents (R57) reviewed for unnecessary medication in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered for 2 of 3 residents (R4, R71) reviewed for medication administration in the sample of 34. This failure resulted in 6 errors out of 30 opportunities resulting in a 20% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications were reordered before running out, resulting in missed doses of lithium and lorazepam for a resident. This applies to 1 of 34 residents (R135) reviewed for medications in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided prescribed therapeutic diets. This applies to 2 of 34 residents (R141, R164) reviewed for therapeutic diets in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for a resident who has a pressure ulcer to prevent cross contamination. This applies to 1 of 34 residents (R170) reviewed for infection control in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to screen, educate, and offer the influenza immunization to a resident upon admission to the facility. The facility failed to administer a pneumococcal immunization to a resident once the resident consented to receiving the immunization. These failures apply to 1 of 5 residents (R163) reviewed for immunizations in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to screen, educate, and offer the COVID immunization upon admission to the facility for 2 of 5 residents (R123, R163) reviewed for immunizations in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a light fixture was in safe operating order. This failure resulted in the light fixture falling from the ceiling, landing on the resident while in bed, and R1 sustaining a second degree burn. This applies to 1 of 3 residents (R1) reviewed for safe physical environment in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R1) from physical abuse by a visitor, and failed to protect a resident (R2) from verbal abuse by a visitor. These failures apply to 2 of 3 residents reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to report abuse allegations to the State Agency for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are dependent on staff for activities of daily living received oral care for 2 of 6 residents (R1, R2) reviewed for oral care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (R112) receiving tube feedings had their weight monitored. This failure resulted in R112 sustaining a significant weight loss. This applies to 1 of 6 residents (R112) reviewed for weight loss in the sample of 32.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was palatable for resident consumption. This applies to 4 of 32 (R71, R38, R103, R34) residents in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and approve a resident to self-administer medications, which applies to 1 of 3 residents (R116) reviewed for self-administration of medication in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from resident to resident physical and verbal abuse. This applies to 1 of 32 residents (R84) reviewed for abuse in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy for 1 of 6 residents (R166) reviewed for abuse policy and procedures in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities to dementia residents to 2 of 32 residents (R70, R111) reviewed for activities in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion (ROM) was evaluated for a brace and received ROM exercises for 1 of 4 residents (R63) reviewed for ROM in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were supervised during medication administration for 2 of 32 residents (R16, R42) reviewed for pharmacy services in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used the required personal protective equipment (PPE) when entering a contact isolation room, and failed to have signs up identifying residents on isolation for COVID-19. This applies to 3 of 32 residents (R78, R54, and R148) reviewed for infection control in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident over [AGE] years of age for their pneumonia vaccination and failed to assess a resident for the influenza vaccination. This applies to 3 of 5 (R27, R23, R17) residents reviewed for vaccinations in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate hand and nail care to 1 of 3 (R1) dependent residents with a hand contracture who were reviewed for improper nursing care; failed to follow facility policies for nail care, morning/nighttime care, and for bed baths. This failure resulted in R1 having a foul odor to her left hand and obtaining an open wound to the palm of her contracted hand that required immediate treatment by the facility's wound care team.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an X-ray was completed and reported in a timely manner, and failed to ensure there was not a delay in treatment after a fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 4. This failure resulted in an almost 24 hour delay in emergency care, and R1 experiencing pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for a resident at high risk for falling for 1 of 3 residents (R1) reviewed for falls in the sample of 4. This failure resulted in R1 experiencing an unwitnessed fall and sustaining a right hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to have an effective process in place for staff to quickly identify a resident's code status. The facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R1) found not breathing and pulseless, whose POLST (Physician Orders for Life-Sustaining Treatment) form showed the resident was a Full Code. These failures led to a delay in R1 receiving CPR and R1 dying in the facility. These failures apply to 1 of 6 residents (R1) reviewed for deaths in the facility in the sample of 6. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when facility staff failed to immediately initiate CPR on R1, when he was found unresponsive and pulseless, due to facility staff not being able to quickly identify R1's code status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 5 residents (R4) reviewed for abuse in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 8 residents (R1) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to assess/monitor a resident for 72 hours after having a fall and hitting their head. This applies to 1 of 3 (R4) residents in the sample of 8 reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident room was free from pests for 1 of 10 residents reviewed for pest control (R3) in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was treated in a dignified manner for 1 of 3 residents (R1) reviewed for dignity in the sample of 3. This failure resulted in R1 being ignored, left naked, and crying after the insertion of a permacath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bulk bin scoop was free of caked-on debris, and that it was cleaned and sanitized in a manner to prevent cross contamination. This has the potential to effect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are dependent on staff for activities of daily living received assistance with incontinence care, oral, and nail care. This applies to 4 of 35 (R333, R130, R88, R41) residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents receiving a puree diet with smooth consistency puree broccoli. This applies to 11 of 11 (R55, R16, R76, R232, R57, R20, R32, R33, R22, R160, and R483) residents reviewed for puree diets in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were put on isolation precautions, which applies to 4 of 35 residents (R382, R175, R176, R6) reviewed for infection control in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to standards of practice for 1 of 35 residents (R65) reviewed for pharmacy services in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents bedding and privacy curtain were clean and changed when soiled to promote a homelike environment for 1 of 35 residents (R41) reviewed for homelike environment in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities for a resident with Dementia. This applies to 1 of 35 residents (R94) reviewed for activities in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide treatment to a resident's heel prior to developing a deep tissue injury, and failed to ensure a resident's treatment dressings were changed. This applies to 2 of 7 residents (R125, R333) reviewed for pressure ulcers in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling catheter bag was maintained off the floor to prevent infection. This applies to 1 of 9 residents (R333) reviewed for urinary catheters in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to ensure nutritional interventions (weekly weights) were completed for a resident with significant weight loss. This applies to 1 of 8 residents (R148) reviewed for weight loss in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer intravenous medications according to standard of practice to 1 of 4 residents (R175) reviewed for medications in the sample of 35 R175's Physician Order Sheet (POS), dated 12/2023, shows R175 has diagnoses of osteomyelitis, diabetes, and arthritis. The same POS shows R175 has an order for intravenous (IV) antibiotic therapy (Cefazolin Sodium Injection Solution Reconstituted 2 gram intravenously (IV) every 8 hours for osteomyelitis (bone infection) bacteremia, and septic arthritis. R175's Hospital Transfer Form, dated 12/8/23, shows R175 has a PICC line (Peripherally Inserted Central Catheter) to his left arm surgically inserted by the hospital on [DATE]. On 12/11/23 at 10:31 AM, R175 was in bed. R175's PICC line to his left upper arm was intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staffing data was posted in a daily basis. The failure affects all residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow a Dietitian's recommendation for weekly weights for a resident with significant weight loss. This applies to 1 of 3 residents (R1) reviewed for weight loss in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a residents room was in a sanitary condition. This applies to 1 of 8 residents (R2) reviewed for home like environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was safely transferred. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8.