Inspection Reports for
Elevate Care Windsor Park

Two deficiencies were cited related to failure to update a resident's care plan after falls and failure to investigate a resident's fall. Both deficiencies affected one resident each and were determined to cause minimal harm with few residents affected.

The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, and failed to implement an infection prevention and control program including transmission-based precautions and proper PPE use.

The facility was found to have failed to keep two residents free from abuse during a physical altercation involving hitting and throwing a milk carton. The investigation included interviews and record reviews documenting the incident and related behaviors.

The facility was found to have multiple deficiencies including failure to obtain informed consent for psychotropic medication, failure to conduct care plan conferences, failure to provide assistance with grooming, medication administration errors, incorrect pressure ulcer prevention mattress settings, failure to provide restorative services, oxygen therapy issues, improper medication storage, food labeling and storage issues, personal refrigerator monitoring failures, missing lids on outside trash dumpsters, infection control lapses with linen handling, and malfunctioning call light systems.

The facility failed to implement their fall prevention policy, resulting in a resident (R1) falling and sustaining a fractured left femur. Staff failed to adequately monitor R1 despite known abnormal seizure medication levels and impulsiveness.

The survey found multiple deficiencies related to the cleanliness, maintenance, and safety of shower rooms across all floors, including broken tiles, missing shower fixtures, soiled linens, and cluttered walkways. Maintenance and housekeeping practices were described but deficiencies remained at the time of survey.

The facility was found to have multiple deficiencies including improper pressure ulcer care, failure to implement enhanced barrier precautions, and inadequate supply of clean bed linens due to laundry equipment malfunction.

The facility failed to ensure the nurse call system was properly working for four of eight residents reviewed, resulting in delayed responses to call lights. Maintenance identified issues with the call light system, and facility policy requires prompt reporting and frequent checks until repairs are completed.

Complaint #145970: The facility failed to investigate and report alleged mental abuse of one resident (R1).

The facility failed to investigate and report alleged mental abuse by a restorative aide toward one resident. The administrator did not consider the incident reportable and did not report it to IDPH.

The facility was cited for failure to ensure that wound care treatments were documented or initialed in the electronic treatment administration record for one resident with a Stage IV pressure ulcer. The deficiency involved minimal harm or potential for actual harm to a few residents.

The facility was found to have multiple deficiencies including failure to follow feeding assistance policies, call light accessibility, advance directives orders, comprehensive care planning, blood glucose monitoring, pressure ulcer care, range of motion care, respiratory care, medication storage and labeling, food service and menu adherence, personal refrigerator food safety, garbage disposal, infection control policy updates, linen handling, and vaccination documentation.

The facility was found to have multiple deficiencies including call lights not within reach for nine residents, non-functioning resident room TVs, unsafe storage of sharp items, improper medication storage, and unsanitary beverage serving practices. The facility failed to ensure a safe, clean, and homelike environment and proper medication management.

The facility failed to ensure delivery of necessary DME for resident R1 prior to discharge, resulting in increased pain and emotional distress. The facility also failed to provide full-time social worker coverage for 12 days, contributing to the discharge without needed equipment.

The facility failed to maintain adequate linen supplies and documentation, ensure proper medication administration documentation, implement infection prevention measures in the laundry area, and maintain wheelchairs in safe working condition for residents. These issues affected multiple residents and posed potential harm.

The facility failed to convey resident funds within 30 days of discharge for one of three residents reviewed.

The facility failed to assess one resident for safe self-administration of medication and failed to report a fall incident to the state reporting agency. Both deficiencies have the potential to affect many residents.

The facility failed to ensure staff wore N95 masks as directed, failed to ensure a resident wore a mask 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 resident. These failures have the potential to affect 180 residents.

The facility was found to have multiple deficiencies including failure to follow call light policy, protect resident privacy, complete timely assessments, develop comprehensive care plans, provide timely ADL assistance, manage pressure ulcers properly, ensure adequate supervision, maintain catheter care, provide nutritional supplements, label oxygen equipment, ensure medication safety, maintain food safety and sanitation, manage garbage properly, safeguard resident records, and implement infection control and vaccination policies.