Inspection Reports for Elevate Care Windsor Park

The inspection was conducted as an annual survey to assess compliance with regulatory requirements, focusing on care plan development and fall prevention interventions.

The facility failed to update a resident's (R1) care plan intervention after a fall and failed to adequately investigate the fall. This failure affected 1 of 3 residents reviewed for falls, with minimal harm or potential for actual harm noted.

The inspection was conducted to evaluate the facility's compliance with wound care treatment, infection prevention and control practices, and proper implementation of transmission-based precautions for residents, specifically focusing on one resident (R1) with an unstageable pressure ulcer and wound infection.

The facility failed to provide appropriate wound care and change wound dressings as ordered, resulting in worsening and infection of a pressure ulcer in one resident. Additionally, the facility failed to implement proper transmission-based precautions, including lack of PPE use by staff, absence of precaution signage, and failure to isolate the infected resident, risking cross contamination to other residents.

The inspection was conducted due to a complaint investigation regarding an alleged physical altercation and abuse between two residents (R2 and R5) during a smoking break on the facility patio.

The facility failed to keep two residents free from abuse, as evidenced by a physical altercation where R2 and R5 exchanged blows and threw a milk carton. Staff were not present outside during the incident. Both residents have documented risk factors for aggression and combative behavior. The facility policy prohibits abuse, neglect, and mistreatment of residents.

The complaint investigation found that R2 hit R5 with an open milk carton and they exchanged physical blows during a smoking break. Staff were not present outside to prevent or intervene promptly. R2 was sent to the hospital; R5 was examined but did not require hospital care. Both residents have risk factors for aggression. The police were not notified.

Routine inspection of Elevate Care Windsor Park nursing home to assess compliance with healthcare regulations including medication management, care planning, restorative services, infection control, food safety, and resident safety.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication, incomplete care plan conferences, inadequate assistance with activities of daily living, medication administration errors leading to sub-therapeutic anticonvulsant levels and seizures, improper low air loss mattress settings, lack of restorative services, oxygen therapy issues, improper medication storage, food labeling and storage deficiencies, personal refrigerator monitoring failures, missing lids on outside trash dumpsters, and infection control lapses related to linen handling and call light functionality.

The inspection was conducted due to a complaint investigation regarding the facility's failure to implement fall prevention policies, resulting in a resident (R1) falling and sustaining a serious injury.

The facility failed to assess the risk for falls and implement appropriate fall prevention interventions for resident R1, who fell and sustained a closed fracture of the neck of the left femur requiring surgical repair. Staff failed to provide adequate supervision and assistive devices despite knowledge of R1's high fall risk and abnormal seizure medication levels contributing to unsteady gait.

The investigation was complaint-driven based on a fall incident involving resident R1 on 11/25/2024. The complaint included concerns about staff administering seizure medication despite abnormal lab levels, inadequate supervision, and failure to monitor R1 closely despite known high fall risk. The complaint was substantiated with findings of actual harm due to the fall and fracture.

The inspection was conducted to assess the facility's compliance with regulations regarding the safety, cleanliness, and functionality of shower rooms and the overall environment for residents.

The facility failed to provide a home-like environment with clean and sanitary shower rooms, with multiple issues observed including broken tiles, missing shower fixtures, soiled towels and linens on floors, leaking pipes, and cluttered shower rooms. Maintenance and housekeeping practices were described but deficiencies remained.

The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, infection prevention and control, and facility safety including linen availability.

The facility failed to ensure appropriate pressure ulcer care by not setting a low air loss mattress correctly for a resident with a pressure ulcer. The facility also failed to implement Enhanced Barrier Precautions (EBP) timely for a resident with a pressure wound, risking spread of multidrug resistant organisms. Additionally, the facility lacked adequate clean bed linens due to laundry equipment malfunction and supply issues, potentially affecting all residents.

The inspection was conducted to evaluate the functionality of the nurse call system in the facility, ensuring it was properly working in residents' bathrooms and bathing areas.

The facility failed to ensure the nurse call system was properly working for four of eight residents reviewed. Observations and interviews revealed that call lights were activated but not illuminated at nurses' stations or outside rooms, causing delays in assistance. Maintenance confirmed the call light system needed updating.

The inspection was conducted due to a complaint regarding the facility's failure to investigate and report alleged mental abuse of a resident (R1).

The facility failed to properly investigate and report an alleged incident where a restorative aide was accused of being mean to a resident. The administrator did not consider the incident reportable and did not report it to the Illinois Department of Public Health. The resident was upset and verbally abusive due to lack of family visits, and the facility's internal investigation procedures were not fully followed.

The complaint involved alleged mental abuse of resident R1 by staff member V8. The facility did not investigate or report the incident to the state agency, concluding the resident was verbally abusive and the incident was not reportable.

The inspection was conducted to assess compliance with pressure ulcer care policies and to ensure appropriate treatment and documentation for residents with pressure ulcers.

The facility failed to follow its policy requiring documentation or initials in the electronic treatment administration record (ETAR) for pressure ulcer treatment for one resident (R94) with a Stage IV sacral pressure ulcer. The wound care was ongoing and improving, but missed documentation could delay healing and increase infection risk.

The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility policies.

The facility was found deficient in multiple areas including failure to follow feeding assistance policies, call light accessibility, care planning, medication administration, pressure ulcer care, range of motion interventions, respiratory care, food service and storage, infection control policies, and vaccination documentation.

The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility standards, including resident care, environment, medication storage, and food safety.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, resident room TVs not in good working condition, unsafe storage of sharp items, improper medication storage and administration practices, and unsanitary beverage serving practices.

The inspection was conducted due to a complaint regarding the facility's failure to ensure a resident (R1) was safely discharged home with the necessary durable medical equipment (DME), resulting in actual harm to the resident.

The facility failed to follow its discharge policy to ensure R1 was discharged with necessary DME, causing increased pain and emotional distress. The resident was discharged without the required wheelchair and bedside commode, which were not delivered on time despite family and staff efforts. The facility also lacked full-time social worker coverage during a critical period, contributing to the failure.

The complaint investigation revealed that R1 was discharged home without the necessary durable medical equipment (wheelchair and bedside commode), causing increased pain and fear of falling. The family was assured equipment would be delivered prior to discharge, but it was not. The social service assistant covering for the social worker on vacation faxed the order but did not follow up. The DME company never received the order. The resident's family purchased equipment out of pocket. The facility lacked full-time social worker coverage for 12 days, contributing to the failure.

The inspection was conducted based on allegations received by the Illinois Department of Public Health regarding insufficient linens and gowns, medication administration errors, infection control issues, and equipment safety concerns at the facility.

The facility failed to ensure adequate linen availability and documentation, medication administration and documentation errors for three residents, improper infection prevention and control practices related to linen handling, and maintenance of wheelchairs for three residents. These deficiencies had the potential to affect many residents.

The inspection was conducted to evaluate the facility's compliance with requirements related to notifying residents of certain balances and conveying resident funds upon discharge, eviction, or death.

The facility failed to convey resident funds to one of three residents reviewed within 30 days of discharge. Specifically, a resident's funds were not returned until 145 days after discharge due to administrative errors in issuing the check.

The inspection was conducted based on complaints regarding the facility's failure to properly assess a resident for self-administration of medication and failure to timely report a fall incident to the state reporting agency.

The facility failed to assess one resident (R8) for safe self-administration of medication before permitting unsupervised use, leaving inhalers unattended at bedside, potentially affecting 64 residents. Additionally, the facility failed to report a fall incident involving another resident (R1) to the state agency within the required timeframe, despite the resident sustaining injuries.

The complaint investigation revealed that the facility did not assess resident R8 for safe self-administration of medication and left inhalers unattended at bedside. It also found that the facility failed to report a fall incident involving resident R1 to the state agency within the required 24-hour period, despite injuries including a closed fracture and hematoma.

The inspection was conducted following allegations received by the Illinois Department of Public Health on 2023-01-11 that the facility was not following guidelines to prevent the spread of Covid-19 infection.

The facility failed to ensure staff wore N95 masks as directed, failed to ensure a resident (R4) wore a mask when outside the room, failed to ensure staff donned required PPE prior to entering isolation rooms, and failed to ensure PPE was readily available for one of four residents (R2) in isolation. These failures had the potential to affect 180 residents.

The complaint alleged noncompliance with Covid-19 infection prevention guidelines. The investigation found multiple failures related to PPE use and mask wearing by staff and residents, and inadequate PPE availability for a Covid-positive resident.

The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements across multiple areas including resident care, medication administration, infection control, and facility safety.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach, protection of private health information, timely completion of resident assessments, development and implementation of comprehensive care plans, timely assistance with activities of daily living, pressure ulcer care, supervision to prevent accidents, catheter care, medication administration errors including expired medications, dietary staff certification, food safety and storage, infection prevention practices, vaccination documentation, and call light system functionality.